Federal law requires insurers to have in-network specialists available to their members, including for certain mental health conditions, such as OCD and PTSD. At times, there is a “gap” in the patient’s coverage, meaning there is not an in-network specialist available who can meet the needs of the patient (E.g., the patient has OCD and there is no in-network provider that has expertise in treating OCD). In these cases, the network is considered “deficient,” and the insurer is required to remedy this.

A Network deficiency exception or NDE (also called the network gap exception or PPO waiver) is an agreement by insurance to reimburse the patient at the in-network rate for an approved out-of-network specialist. All covered costs should also apply to the in-network deductibles and in-network annual out-of-pocket maximums.

The NDE is different from a single-case agreement, which requires the provider to step into the insurance network for a single patient. Single-case agreements require the provider to negotiate with and receive payment from the insurance company. At SOAR, we do not negotiate rates or contracts, accept single case agreements (SCAs), or letters of agreement (LOAs) due to time, resources, and restrictions place by insurers.‍ ‍

All NDE agreements with insurance are between the patient and their insurance company. Fees are charged by the provider at the time of service. Patients are responsible for requesting and receiving reimbursement from their insurance company. The provider gives the patient a a statement (called a “superbill”) that includes the diagnosis and service codes needed by the insurance company for reimbursement.

Approach this process with patience, assertiveness, and a calm mindset. It can be frustrating and long due to the complexity of insurance systems, so stay kind and persistent when speaking with representatives.

Document all of your interactions with insurance. Keep an organized folder of all the interactions with insurance. Keep detailed notes including names, job titles/roles, dates, and reference numbers for calls, approvals, and denials. Be prepared for miscommunications between departments.

Keep in mind that many agreements will have an expiration date and will need reauthorization. Make sure to note this when receiving authorizations and revisit them before they expire. Advocacy for yourself and your loved one will be ongoing.

Before starting treatment (or as soon as possible), contact your insurance provider by calling the number on the back of your insurance card.

The first person you talk to will most likely be unfamiliar with the NDE or PPO waiver process, even though they may think they do. Ask to speak with a “case manager” or “care advocate” about getting out-of-network coverage at in-network rates. Sometimes you may need to ask for someone who handles “single case agreements” or “letters of agreement.” Although this is not what you are looking for (again, you are looking for a NDE/PPO waiver/gap exception), this may lead you to the right person.

If a corporate employer provides your insurance, there may be a human resources team member, appointed liaison, or representative for the insurance company available through your employer who can help you navigate this process.

This first step can be the most frustrating part. Sometimes calls and wait times are long, so pick a time to call when you are not rushed and have something else to do while you wait on hold. Remember, stay calm and be prepared to educate the representatives you speak with. If you encounter difficulties, ask to speak to a supervisor or consider ending the call and calling back to get a fresh start with a different representative.

Your insurance will likely assert that they do have in-network providers that treat OCD. It’s critical for you to explain the reason you need an OCD specialist and the difference between general therapists and OCD specialists.

Research the providers they suggest, and if they aren’t OCD specialists, share your findings with the insurance company. Explain any previous unsuccessful experiences you may have had with non-specialist therapists. There may be other reasons the providers on the list are not appropriate for you: Do they treat the age group you need (fewer providers treat children and adolescents)? Are they within a 10-mile radius of where you live? Are they accepting new patients within a reasonable amount of time? Make sure to make these points with your insurance, as well.

Emphasize that specialist treatment is a better investment despite its upfront cost. Present the case that you are trying to save them money by getting faster instead of making them spend more money over a long period of time on ineffective therapy. This is the bottomline with insurance companies, unfortunately.

To request out-of-network coverage at in-network rates, your insurance will need specific details about the OCD specialist you'd like to work with. These include:

• Provider Name

• Practice Name

• Practice Address

• Practice Phone/Email/Fax

• Provider Degree Type (e.g., PhD, MA, MSW)

• Provider License Type (e.g., Psychologist, Licensed Professional Counselor [LPC], Licensed Independent Social Worker [LISW], Licensed Marriage & Family Therapist [LMFT])

• Provider License Number (can be found via the relevant state licensing board; e.g. Texas: )

• Provider Tax ID Number

• National Provider Identification or NPI Number

• Patient Diagnosis Code(s) (e.g., the most common DSM-5/ICD-10 diagnosis code for OCD is F42.2, although there are more than one)

• Procedural Codes/Service Codes/CPT Codes (see more, below)

Ask your preferred specialist for their common CPT codes. Common CPT codes for therapy at SOAR include:

• 90791 – Diagnostic Intake*

• 90837 – Psychotherapy, 53-60 min*

• 90834 – Psychotherapy, 38-52 min*

After you receive and pay for services, all of the numbers and exact codes that are relevant to your care will be provided to you on a Superbill (or Statement for Insurance Reimbursement”).

Sometimes, insurance companies will prefer to speak directly with your provider or conduct a clinical case review. Be patient, as this process can be time-consuming for therapists, who may bill for the time spent. While it often increases the chance of getting more coverage for your therapy, it is not guaranteed.

Hooray! You’ve gotten the approval letter for your NDE! Keep that letter handy and submit it along with the superbills with every request for reimbursement. This may help prevent problems with your reimbursement (eg, your claim is not reimbursed at the in-network rate or not applied to in-network deductibles/OOP max). Check the details of every reimbursement and follow-up if there are any discrepencies.

Ensure you fully understand the agreement between your insurance company, provider, and yourself. Get everything in writing, including details about reimbursement rates, service codes, deductibles (in-network vs. out-of-network), session limits, and coverage periods (typically 6 months to a year).

If any issues arise, you may need to revisit previous steps or speak to someone new in your insurance company. If the process becomes too challenging, consider whether it's worth continuing or exploring legal representation as a last resort.

If you are denied the NDE, you have recourse to file an appeal or file a formal complaint with your insurance. The appeal process is first. If the appeal is denied, advance to the formal complaint. Use the term “formal complaint,” as this is strong language to insurers and may encourage them to come to an agreement. For more assistance and guidance on this process, visit www.CoverMyMentalHealth.org.