A Network deficiency exception (also called the network gap exception) is an agreement by insurance to reimburse the patient at the in-network rate for an approved out-of-network specialist. This occurs when there is a “gap” in coverage, meaning when there is not a specialized provider to offer those services within the network of the patient's insurance (E.g., SOAR provides ERP, exposure and response prevention for OCD).

It is important to note that this does NOT go towards patients out-of-network benefits. It is a way to become eligible for insurance reimbursement, if gap exception is accepted.

This is different from a single-case agreement. 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.‍ ‍

All agreements with insurance are between the patient and their insurance company. Fees are charged at the time of service. You are responsible for requesting and receiving reimbursement. Superbills are available in the Client Portal to assist you with this.

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.

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

Advocacy for yourself and your loved one will be ongoing as many agreements have an expiration date. Make sure to note this when receiving authorizations and revisit them before they expire. If needed, consider professional help like Reimbursify.

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

Ask to speak with a “case manager” or “care advocate” about getting out-of-network coverage at in-network rates. If they’re unfamiliar with this, ask for terms like “single case agreement” or “letter of agreement.” This is not what you are looking for (you are looking for a network exception/gap exception) but 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 who can help you navigate this process.

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.

Your insurance may suggest in-network providers, but it’s important to explain the difference between general therapists and OCD specialists.

Research their suggested providers, 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? Make sure to make these points, as well.

Emphasize that specialist treatment is a better investment despite it's 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.

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*

• Modifier 95 for telehealth [typically billed for commercial insurance]*

• Modifier GT for telehealth [is typically used with Medicare/Medicaid]*

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.

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).

Follow up to confirm the agreement is being honored. 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.