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Tip of the Week: What is a GAP Exception and how to get one - 4-2-15 to 5-1-15

Wednesday, April 29, 2015

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Pre-authorizations and GAP Exceptions

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Tip of the Week!

What is a GAP Exception and how to get one


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"


The Golden Rule for GAP Exceptions:

Don't give up so easily!

If your GAP Exception request is denied, make sure to find out why. We have seen, many times, insurers deny GAP Exception requests on the basis they that there are in-network providers for the patient to go to, only to find out upon further investigation that the in-network providers that the insurer provided do not provide the service needed!

For example, an insurer may mistakenly identify DME and/or orthotics suppliers that supply equipment such as CPAP machine, wheelchairs, etc, instead of a DDS/DMD for oral appliances for obstructive sleep apnea.

If you find an error, ensure to appeal the decision and it will likely be overturned.

Below is a sample of an approval from an insurer for a GAP exception request from a dentist for an oral appliance for obstructive sleep apnea:

Looking for more in-depth training for Medical Billing in Dentistry?

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Join NPM for our "Successful Medical Billing in Dentistry" CE courses held across the country!

Our next course Medical Billing course coming up is May 1st and 2nd in Washington DC! Then we'll be in San Diego June 26 & 27.

There are plenty of other dates and cities if that one doesn't fit your schedule:

Watch any past NPM Study Group on demand!

The sessions are organized into categories to help you find what you're looking for - or something you didn't even know you were looking for!

1. Sleep Apnea Training

Dental practice training for managing, treating and medical billing for obstructive sleep apnea with oral appliance therapy

2. TMD-TMJ Training

Training for dental practice for managing, treating and medical billing for TMD/TMJ services - temporomandibular joint disorders

3. Oral Surgery Training

Training for medical billing for medically necessary oral surgical services for the dental practice

4. General Medical Billing Training

Various general medical billing in dentistry training for the dental practice

5. Marketing Training
Marketing for medically necessary procedures in the dental practice training

6. Training - misc. topics

Misc. topics for training for dental practices treating and billing for medically necessary procedures

7. Recorded E3 Full Webinars
Full length training on DentalWriter software by treatment type

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