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Updated on Thursday, June 16, 2016
With the price of insurance and medical care rising each year, many Americans need help containing medical coverage costs to avoid bankruptcy. One way to limit medical costs is by obtaining coverage gap exceptions which allow insurance holders to receive out of network benefits at in network prices.
Consumers willing to fight for a coverage gap exception may save thousands of dollars on a single procedure.
What is a coverage gap exception?
A coverage gap exception is a waiver from a healthcare insurance company that allows a customer to receive medical services from an out of network provider at an in network rate.
A person requesting a coverage gap exception knows the insurance company covers the requested benefits, but the consumer believes that in network providers cannot provide those benefits. It is up to consumers to make a case for the insufficiency of the network to provide the necessary treatment. Consumers can do this by requesting a coverage gap exception waiver.
A coverage gap exception is not the same as appealing a denied claim. A gap exception is a preemptive request for known benefits. Appealing a denied claim involves a request for benefits coverage that the insurance company does not believe it should have to pay. Denied claims go through a different appeals process than the pre-emptive coverage gap exceptions.
When should I consider requesting a coverage gap exception?
The most common requests for coverage gap exceptions surround prenatal and delivery coverage (especially for midwife supervised births), specialized surgeries (such as heart surgery, etc.), and occupational or physical therapy. Anyone who cannot get the benefits they need from an in network provider should apply for a coverage gap exception.
How do I request a coverage gap exception?
Start the coverage gap exception request at least 45 days prior to a procedure to allow insurance companies enough time to grant the waiver prior to the procedure. These are the steps you should take:
- Have your general practitioner or specialist write a letter of necessity outlining the procedure being requested.
- Set your procedure appointment with the out of network provider (giving yourself at least 45 days if possible).
- At the time you set the appointment request all of the following:
- CPC Codes (These are Medical Billing Codes)
- Date of Appointment
- Location of Appointment
- Name of provider
- Whether or not the operation/procedure is inpatient or outpatient.
- Have your specialist, surgeon or primary care physician call your insurance company and request a coverage gap exception waiver. They need to provide all the information that you collected in the first steps.
- Your doctor will need to request a case reference number from the insurance company regarding your coverage gap exception.
- Follow up with your doctor (or their office manager) until you receive a case reference number from the doctor.
- Call your insurance company and request to speak to a rapid resolution specialist who can follow up using your case reference number. Once your doctor makes the request, your insurance company will decide within 7-10 days.
- Request to receive the decision in writing, and be sure to clarify EXACTLY what the waiver includes. You will need all parts of the procedure to be treated as in network.
If you’re seeking coverage for a home birth or birth center coverage, your approach will differ.
- Check that your insurance covers midwifery care in the same way that it covers all other prenatal/delivery/postnatal care. You may need to call your insurance company to determine this is the case.
- Call your insurance company to request the names and contact information for practicing midwives.
- Call and email in-network midwives to determine if they provide the service you are seeking (birth center or at home birth). Keep documentation for each of these emails.
- Find a midwife/birth center that has worked with insurance companies in the past and request CPC codes that are customary in their billing. You will also need their credentials, and contact information.
- Call your insurance company and request to speak a representative to request a coverage gap exception waiver. You should be able to request the waiver over the phone.
- If the representative does not allow you to file, ask to be connected with a supervisor and insist upon filing a coverage gap exception. A case number and a coverage gap exception claim should be started before you hang up.
- Within 7-10 days your insurance company should call you back with an answer. If the appeal is denied on the basis that an in-network provider can provide the same service, ask for the name of the provider, and check it against your list.
Should I appeal if coverage gap exception is denied?
If your insurance company denies your coverage gap exception, they have 30 days to let you know in writing, but you can find out via phone within 7-10 days. It is worthwhile to appeal a denied coverage gap exception. Oftentimes, insurance companies deny gap exceptions based on incorrect information.
An appeal should take a written form, and it should be mailed, emailed and faxed to your insurance company. The appeal should include the letter of necessity (or a letter you write yourself in the case of a home birth request), along with documentation of efforts to find in network providers, and all the information regarding CPC codes, provider name, location, date, and time of appointments. The appeal will go to the person who denied your original request or their supervisor.
If the coverage gap exception is not granted upon appeal, read the response and include any additional information that will help your case. Additional documentation from your doctor or specialist may help in this effort.
The second appeal should also be written and should include all the information to date (including the insurance company’s denial letter), along with any updated information. The second appeal will go to a division of your insurance company that deals with coverage gap exceptions.
Insurance companies view a second appeal as a final appeal, and to pursue the matter further will require help from a patient healthcare advocate or a lawyer and possibly the Division of Insurance Enforcement in your state.
What rights do I have in the coverage gap exception process?
Insurance holders should feel confident that they can exercise these rights at any time:
- The right to receive, in writing, the insurance company’s policy and process for requesting coverage gap exception waivers.
- The right to request clarity on all decisions.
- The right to receive all decisions in writing.
- The right to appeal any decision by your insurance company (up to two times).
- The right to contact your state’s Division of Insurance Enforcement for further help
Who can help me?
Receiving a coverage gap exception involves phone calls, paperwork, and persistence, but you may not be on your own.
If you hold insurance through an employer sponsored health plan, then your employer may have a participant advocacy specialist with experience applying for coverage gap exceptions. Specialists offer advice targeted towards your insurance provider, and they can review your case and help you write appeals letters. Participant advocacy specialists may be your most helpful ally in the coverage gap exception process, and you may enlist them even before you’ve filed for a gap exception.
Insurance plans purchased through the insurance marketplace do not offer participant advocacy specialists, but Patient Advocacy Foundations may provide not for profit help in your county. These foundations specialize in denied claims, but they may help you connect with helpful resources.
Finally, every state has a Division of Insurance Enforcement. If you believe your request has been denied without merit, you may contact your state’s Division of Insurance Enforcement to learn more about how to this government agency can help fight for your consumer rights.