Hi drgreeno!

Great question, you pretty much explained it!

Put simply: A GAP Exception (also referred to as a network deficiency, gap exemption, gap waiver, etc) is a request to an insurer from an out of network provider, requesting that the patient's in-network benefits be honored on a one time basis. This is generally requested when the patient is unable to locate an in-network provider who can perform the services/treatment they require.

GAPs can come in a few forms and fashions.....
- sometimes, the GAP will apply to the patient' coverage only, but not effect you being required to follow in-network provider guidelines or not (i.e ability to balance bill the patient)
- sometimes, the GAP will honor the patient's in-network coverage, but also require you to follow in-network guidelines (i.e. not balance bill your patient beyond anything beyond deductible and co-insurance....you are "accepting their fee schedule").

When requesting a GAP - it is important to explain you are requesting the patient be able to exercise their in-network benefits, but to you as an out of network provider. Let them know it is due to geographical necessity, as the patient has not been able to locate an in-network provider within a reasonable distance that they can go to.

GAPs can be sent to insurers as written requests or requested over the phone in some cases.

Hope this helps! Let us know if you have any further questions.