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A GAP Exception (also referred to as a network deficiency, GAP Waiver, in-for-out, etc) is a request to honor a patient's in-network benefits, even though they are seeing an out-of-network provider.
This can be advantageous for the patient depending on their policy benefits. A GAP Exception allows the patient to utilize their in-network benefits, which usually have a lower deductible and higher coverage percentage. This can also be key in obtaining any coverage at all if the patient has a policy that only offers in-network coverage and the provider they are seeing is out-of-network, for example, many HMO policies only offer in-network coverage.
Keep in mind, a benefit verification should be performed before making the decision to request a GAP exception, as this will reveal what the best next step is. In most cases, a patient's in-network benefits will yield less out of pocket expense for the patient, so a GAP exception would be advantageous. However, there are exceptions to this! For example, a patient may have seen many out-of-network providers that year and already met their out-of-network deductible, however not met any of their in-network deductible yet. This is why the benefit verification is key.
If the provider is out-of-network, and the policy only offers in-network coverage, a GAP Exception will be necessary to obtain any coverage.
Why would an insurer allow in-network coverage to an out-of-network provider?
In short, an insurers allow GAP Exceptions because they do not have an in-network provider for the patient to go to, so it is considered a "network deficiency".
Many insurers will allow a GAP Exception if there is not an already a provider contracted in their network rendering the same services within a reasonable distance to the patient. The insurance company determines what the reasonable distance is, which generally lies between 30-50 miles.
How to obtain a GAP Exception for your patient:
Some insurers will accept a written mailed or faxed request from the provider, while some insurers will require the patient call to make the request. Below is an example of language for a GAP exception request:
"There are no in-network providers within a reasonable distance to this patient who can provide this treatment/service/equipment.
Please honor the patient’s in-network benefits to this out of network provider on a one time basis as a courtesy to your beneficiary to receive the medically necessary treatment they have been prescribed by their physician"
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