In-Network Exceptions

June 09, 2023

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This article is a part of our
Health Insurance and Autism Series.

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In-Network Exceptions for Insured Health Benefits Plans in New Jersey

The following article was written by The New Jersey Association of Health Plans, a nonprofit association representing leading Commercial and Medicaid health care plans in New Jersey and proudly covering over 7 million New Jersey residents, in conjunction with Autism New Jersey.

If a Member is having a difficult time finding a network provider that is available to see that Member within a reasonable period of time – or one that is a reasonable distance from their home – the Member should call the Member Services number on their insurance ID card to seek assistance. Some carriers may have a special number for behavioral health services, which the Member can try as well. If the carrier suggests network providers that are unavailable or located too far away, the member may consider requesting what is called an “in-network exception” or sometimes called an “in-plan exception.” The Q&A below may provide some general background on this process.

Q1: What is an “in-network exception?”

A: An in-network exception is a way for Members to get their health insurance to pay for treatment with an out-of-network provider under certain, specific circumstances. New Jersey regulations require an HMO, service corporation, or an insurer (any of which might also be called a “carrier”) with a network plan to provide or arrange for health care services for its enrollees for specified services, including behavioral health care services (e.g., N.J.A.C. 11:24-5.1(a)).

However, there may be times when the medical services are not available within the network, not available within a reasonable period of time, or not available within a reasonable distance within the network as described above. In such cases, if the Member or the Member’s primary care physician (PCP) have made reasonable efforts to access the services in network and has documented those efforts, the Member or PCP may request that the carrier grant what is called an “in-network exception,” where the carrier provides coverage for medical services rendered by an out-of-network provider at a level of coverage and cost share equivalent to that which would be applied to the same services if rendered by an in-network provider.

Q2: How do I initiate a request for an in-network exception?

A: Each carrier may have its own procedures for initiation of an in-network exception, but generally the Member can call the carrier’s Member Services number or Behavioral Services number (the phone number will be on the ID Card). If a PCP is calling on behalf of a member, they will typically reach out to the carrier’s Provider Services department.

The in-network exception request must be made before the services are rendered and documentation, including a summary of efforts that have been made to access the required services within the Member’s network, must be supplied to the carrier at the time of the request.

Q3: When will a carrier grant an in-network exception?

A: The Member must consult with the carrier. Generally, a Member will need to show that:

  1. The service sought is a covered service under the Member’s health benefits plan;
  2. The service is medically necessary;
  3. The Member made efforts to access the required services in-network without success, and has documented those efforts; and
  4. There is no in-network provider within the Member’s geographic area with the capacity to provide the desired service and to do so within a reasonable time frame.

Q4: Will I be granted an in-network exception if there are available providers in my network?

A: Generally no. The in-network exception process is not set up to accommodate a Member’s personal preference of providers. Rather, it is designed to provide access if network access is not available.

The Member might need to show that there are no available in-network providers, despite the carrier’s expeditiously undertaken efforts to secure an in-network provider appointment within the time frame and distance parameters set forth above. Only after the Member has done so, and the carrier has determined that based on both its unsuccessful efforts to obtain an appointment and reviewed the documentation the Member submits, might the carrier grant an in-network exception.

Q5: Is a network exception available if I am outside my carrier’s service area?

A: No. The network exception is not available to those traveling outside of the carrier’s approved service area except in cases of emergent or urgent circumstances. So, for example, non-emergency services for a person traveling outside of the carrier’s approved service area would not be eligible for an in-network exception.

*This is intended as general information, not legal guidance. Each person’s benefits are subject to the terms, conditions and limitations set forth in the Member’s contract or certificate and to applicable law. Each carrier may have differences in administrative policy.

Originally posted: 3/18/2017
Updated: 6/9/2023


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