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Gap exception request template

Use this to ask your plan to cover an out-of-network surgeon at in-network cost sharing because no in-network provider can perform your procedure. Attach the log of every in-network surgeon you called. The log is the case; the letter is only the wrapper around it.

Applies to Any plan with a provider network. Insurers also call this a network exception or network deficiency request.

When to send this

None of its own — the surgery date is the real clock. But ASK FOR ONE in the letter: a pre-service decision has a required turnaround under 29 CFR 2560.503-1(f), and naming it converts an indefinite wait into a deadline you can point at later.

Get the number for this letterThis template asks you to state how few in-network providers can furnish the care. Count what exists near you first.

What to do

  1. Get the plan's own in-network list first

    Ask in writing for in-network providers who perform your named procedure. You need their list, not a specialty directory.

  2. Call every name and log it

    Date, name, reference number, and outcome. This attachment is what the request rests on.

  3. Send the request and keep proof

    Portal message with a saved confirmation, or certified mail.

  4. Ask separately whether a single case agreement is needed

    This request sets your cost sharing. It does not settle what the plan pays the surgeon.

The request

[Your name] · [Member ID] · [Today's date]

To: [Plan, prior authorization or network department]

Re: Request for a gap exception (network exception) — [procedure, with CPT codes if known]

I am requesting a gap exception so that [surgeon name, NPI if known] may be covered at in-network cost sharing for [procedure] scheduled for [date, or to be scheduled].

No in-network provider is able to perform this procedure. I contacted every in-network provider on the list your plan supplied on [date]. The results are attached: [N] providers contacted, of whom [N] do not perform this procedure, [N] are not accepting new patients, [N] could not offer an appointment within a clinically reasonable time, and [N] were listed as in network but are not.

I am requesting: (1) approval of the gap exception at in-network cost sharing; (2) written confirmation of the approval, its effective dates, and the procedure codes it covers; and (3) confirmation of whether a single case agreement with this provider is also required, and its status.

If this request is denied, please treat this letter as also requesting the plan's network adequacy analysis for this procedure in my service area, and provide the appeal deadline. Please also confirm the date by which you will decide this request, and the plan provision or regulation setting that timeframe. My understanding is that a pre-service decision is due within the timeframe set by 29 CFR 2560.503-1(f), and sooner if the request is urgent.

[Signature] · [Phone] · [Address]

Both stay on your device. Neither one sends anything to this site.

The attachment that matters

A table with one row per provider: name, phone, date called, who you spoke to, reference number, and outcome. Without it this is an assertion. With it, it is a record the plan has to answer.

Common questions

What if the plan says its network is adequate?
That is a factual claim your log contradicts provider by provider. Ask them to identify which in-network provider can perform the procedure and when.
Does approval mean my surgeon gets paid?
Not by itself. Cost sharing and provider payment are separate. Ask about a single case agreement in the same breath.

Where to go next

Sources for the legal points on this page

The ACA appeal framework: internal appeal, then binding external review

Federal — non-grandfathered group health plans and issuers · effective in force

29 CFR 2590.715-2719 — (b)(2)(ii)(B) urgent-care 72 hours, (b)(2)(ii)(F)(1) deemed exhaustion, (c)(2)(xi) state external review binding, (d)(2)(i) four-month federal external review window, (d)(2)(iv) immediate coverage on reversal; 29 CFR 2560.503-1 — (c)(2) no more than two appeals before civil action, (h)(3)(i) 180 days from receipt, (h)(3)(ii) independent reviewer, (h)(3)(iii) health professional on medical judgment

Status: settled · source-checked 2026-08-06 · primary source verified: 2026-08-06

Also on this page, without a citation yet

  • That any plan calls this a gap exception, or that a response is owed on the timeframe named in the letter. The request goes by several names, and whether the pre-service timeframes apply to a network-exception request as opposed to a prior authorisation is not something this page verified. Asking for the date in writing is useful regardless of which rule governs.

These are specific and checkable and we have not yet checked them against a primary source. Treat them as a starting point rather than as settled, and do not put them in an appeal without confirming them.

Last updated 2026-08-09Not legal or medical advice