Billing basics

Network gap exceptions for pediatric therapy — how families get in-network rates

If no in-network provider offers your specialty within a reasonable distance, the family can ask their plan to cover you at in-network rates. It's called a network gap exception — and pediatric specialties win them more often than you'd think.

When a gap exception applies

• No in-network provider with the needed specialty (e.g., pediatric feeding therapy, pediatric ABA) within the plan's access standards
• In-network providers exist but have waitlists incompatible with medical need
• Continuity of care — the child was mid-treatment when the provider left network

How families request one

1. Step 1

   Call before starting care (ideally)

   Member services logs a gap exception or network adequacy request. Retroactive requests are harder but possible.

2. Step 2

   Document the gap

   The family lists in-network providers contacted, waitlist lengths, and distances. Screenshots of the provider directory help.

3. Step 3

   Provide clinical support

   A referral letter stating the required specialty and urgency — plus your credentials and NPI — anchors the request.

4. Step 4

   Get the decision in writing

   Approved exceptions come with an authorization number and effective dates. Claims then process in-network.

What your practice can do

You can't file it for them, but you can hand families a one-page packet: your specialty description, credentials, NPI/TIN, and typical CPT codes. Practices that make gap requests easy convert waitlist-stuck families that would otherwise never start.

Educational content only — not billing, legal, or tax advice. Verify payer policies and regulations for your state and situation.