How to request an out-of-network exception for therapy

An out-of-network exception asks a plan to cover a named out-of-network therapist at in-network cost because no network clinician can provide the care. It goes on the plan's own form with a clinical rationale, and a Medicaid managed care plan must cover the service out of network while its network cannot (42 CFR 438.206(b)(4)).

What is an out-of-network exception, and how is it different from a single case agreement?

An out-of-network exception is a request that asks a plan to cover a named out-of-network clinician at in-network cost because no in-network clinician is available or fits the care. The request goes by several names, a network exception, a network gap exception or an out-of-network exception, and no source unifies the terms. A single case agreement is a different document, the contract a plan may sign to pay one provider for one member, and the exception is the coverage request.

When does a plan have to cover an out-of-network therapist?

A Medicaid managed care plan must cover a necessary service out of network, adequately and in a timely way, for as long as its network cannot provide it, and the enrollee's cost may be no greater than in network (42 CFR 438.206, paragraphs (b)(4) and (b)(5)). The out-of-network provider coordinates payment with the plan.

States set appointment wait time standards for routine Medicaid managed care appointments. For outpatient mental health and substance use disorder services, adult and pediatric, where the plan's contract covers them, the standard is the state's timeframe but no longer than 10 business days from the date of request (42 CFR 438.68, paragraph (e)). That standard applies from the first rating period for contracts beginning on or after three years after July 9, 2024.

A qualified health plan must keep a network sufficient in number and types of providers, including mental health and substance use disorder specialists, so services are accessible without unreasonable delay (45 CFR 156.230). That rule sets network standards and continuity rights with no exception process or clock, so the route is each plan's own.

What goes in the request and the clinical rationale?

A network exception request goes on the plan's own form with a clinical rationale, and Evernorth's Outpatient Behavioral Network Exception Request Form (Rev. 03/2024), one insurer's form, asks why the clinician's specialties are clinically relevant for this member and uniquely available from this provider as opposed to another clinician in its network.

The form tells the clinician to complete it, save it and email it, which it marks as preferred, or fax it, to the address and number printed on the current form. It says omissions, generalities and illegibility will get the request returned for completion or clarification, and it warns that the information on it may be released to the patient or the patient's representative.

The table sets out the rules and the form behind a network exception request.

Where do you send a network exception request, and how do you prove it arrived?

A network exception request goes by the channel the plan's own form names, and a fax delivery record shows the date and time the pages reached the plan's line. Evernorth's form takes email, which it marks preferred, or fax, at the details printed on its current copy, so take the address and number from the plan's current form.

The decision clocks in the table run from the plan's receipt of the request, so keep the delivery record with a copy of the form and the rationale. How to tell if a fax went through shows what to look for in one.

How long does the plan have to decide a network exception?

The Medicaid managed care, exchange plan and group health plan rules cited here set no clock for the exception itself; the clocks around it are Medicaid managed care's 7 calendar days for a standard authorization decision and a group health plan's 15 days for a pre-service claim.

A Medicaid managed care standard authorization decision may take no more than 7 calendar days after the plan receives the request, for rating periods that start on or after January 1, 2026 (42 CFR 438.210). The plan may add up to 14 calendar days when the enrollee or the provider asks for them, or when it justifies a need for more information and how the extra time serves the enrollee.

A pre-service claim is any claim for a benefit that a group health plan conditions, in whole or in part, on approval in advance of the care. The plan decides it within a reasonable period appropriate to the medical circumstances and no later than 15 days after receipt, and it may extend the period once, by up to 15 days, for matters beyond its control (29 CFR 2560.503-1).

What gets a network exception request sent back?

A network exception request is sent back when it has omissions, generalities or illegible entries, or when its rationale does not say why the specialty is uniquely available from this clinician:

• Omissions, generalities and illegibility: Evernorth's form says each returns the request for completion or clarification.
• A rationale that names a specialty without saying why it is clinically relevant for this member and uniquely available from this provider as opposed to another clinician in the network.
• Care given before a required prior approval, such as the approval North Carolina Medicaid has an out-of-network provider get from the member's plan before any service other than emergency and post-stabilization care (North Carolina Medicaid).
• A saved copy of an older form revision, since the email address and fax number belong to the plan's current form.
• A rationale written for the plan alone, since the form warns that its contents may be released to the patient or the patient's representative.

How do Medicaid plans, exchange plans and Texas plans handle the same request?

Medicaid managed care plans, exchange plans and Texas plans each carry a different rule behind a network exception, and the request route is each plan's own. Medicaid managed care plans in every state carry the 438.206(b)(4) duty, so the plan's form or instructions name the channel and any prior approval step.

Exchange plans carry the 156.230 network standards, and on the Federally-facilitated Exchange, in a state CMS has not found to have an effective provider access review program, they must meet appointment wait time standards the Exchange sets for plan years beginning on or after January 1, 2025. Texas preferred provider plans must make routine care for behavioral health conditions available and accessible from preferred providers within two weeks, and under Insurance Code 1301.005(b) an insurer reimburses a non-preferred provider at the preferred level when the service is not available from a preferred provider in the service area (Texas Insurance Code chapter 1301).

The same pattern covers drugs and testing. A formulary exception is a request with a prescriber's rationale (how to fax a formulary exception request), and psychological testing prior authorization uses a plan form and a clinical rationale too (prior authorization for psychological testing).

How do you send a network exception request securely and get the answer back?

A therapist faxes a network exception request securely through a HIPAA fax service under a signed BAA, on the practice's own number, so the plan's answer comes back to the same line. Fax Pigeon includes a BAA signed at signup and unlimited people on every plan, and the plan's current form uploads as it is, whether a PDF, a Word file or a phone photo, with a cover sheet optional. Paid plans fax from the practice's own number, and the plan's answer lands in a shared inbox with roles and assignment. Each delivered fax gets delivery proof, and HIPAA fax for therapists sets out the plans for a therapy practice.

* Official sources (the eCFR, the Texas Legislature, Evernorth, North Carolina Medicaid) were read on October 26, 2026. Fax Pigeon prices and plan terms as of October 26, 2026.