What to do
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.
Call every name and log it
Date, name, reference number, and outcome. This attachment is what the request rests on.
Send the request and keep proof
Portal message with a saved confirmation, or certified mail.
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.
[Signature] · [Phone] · [Address]
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.