How to Get Insurance to Cover Out-of-Network Fertility and Maternity Home-based Nursing: The Network Gap Exception Option | Childress Nursing Services

CNS
Jan 1
5 min read

A gentle, simple Health Insurance Gap Exception guide from

Childress Nursing Services

If you are reading this, you might be feeling stressed.

Maybe you just received your Childress Nursing Services complimentary insurance benefits check email (or an insurance portal message for a different healthcare service), and it showed out-of-network for your plan. This can happen, even if your plan was in-network the year prior, especially at the start of the year when health insurance providers or plans get changed.

First, you are not doing anything wrong. Insurance language can be confusing, even for people who deal with paperwork all the time. And when you are trying to grow a family, the last thing you need is another barrier.

This article is here to help you understand one option many people may not know about:

A Network Gap Exception.

What is a network gap exception?

A network gap exception is a special request you make to your insurance company.

You are asking them:

“Please cover Childress Nursing Services like an in-network provider, because my plan does not have a good in-network option for the care I need.”

Some insurance companies use different names, like:

network gap exception
gap exception
network exception
single case agreement

The name can change, but the idea is the same.

Why this matters for fertility and maternity (and other service) clients

Fertility and maternity care can be time-sensitive.

For fertility clients, medication schedules can be strict. Timing matters. Missing a window can create stress and extra cost.

For maternity clients, support can be needed quickly. Pregnancy and postpartum needs can change fast.

Many families also need care that works in real life. Not just on paper. In-home nursing care can help when:

your schedule is tight
you are exhausted
you need privacy
you do not have adequate support at home
you want skilled nursing care where you feel most comfortable

Childress Nursing Services is focused on access, equity, and safe skilled nursing in the home for fertility, maternity and family home nursing clients. That is why this exception may be worth trying.

The important timing truth

A network gap exception can take several weeks.

So it is best to start early, like:

when you start exploring fertility treatment
when you are trying to conceive
when you find out you are pregnant
when you start planning postpartum support

Even if you are already in a cycle or already pregnant, you can still ask. But earlier is better.

If you are thinking, “I wish I knew this sooner,” you are not alone. Most people are never taught this.

Step-by-step: How to ask your insurance company

Step 1: Call the number on the back of your insurance card

Say something like:

“Hi, I want to ask about a network gap exception. I need a service, but I cannot find an appropriate in-network provider for this care. Can you tell me if my plan allows a gap exception or single case agreement?”

If the insurance rep sounds confused, try this:

“I am asking for an out-of-network provider to be covered at in-network rates, because there is not an appropriate in-network option available for this service.”

Step 2: Ask what they need from you

Ask these questions:

“What is this process called on my plan?”
“Do you have a form I must complete?”
“Do I need prior authorization?”
“Do you need a letter from my fertility clinic, pregnancy, or primary care provider?”
“How long does approval usually take?”
“Is there a faster review option, if care is time-sensitive?”

Write down the answers.

Step 3: Get a call reference number

Before you hang up, ask:

“Can I have a reference number for this call?”

This helps if you have to call again later.

Step 4: Send Childress Nursing Services the form or instructions

If your insurance company gives you:

a form
a portal link
a checklist of documents

Send it to our front office.

If the insurance form has a provider section, Childress Nursing Services can fill out our part.

Important note: your insurance company may ask for a ICD-10 diagnosis code information. Your diagnosis code must come from your fertility clinic, OB, midwife, or ordering provider. We do not diagnose clients. If your insurer wants more specific billing information or ask for something that you've never heard about: write it down and then reach out to our office, so we can get that info to you promptly.

Step 5: Wait for written approval

This is very important.

Do not rely on verbal approval. Ask for written approval that shows:

the dates covered
the service covered
whether you still have a deductible, copay, or coinsurance

If you do not get it in writing, it is harder to protect you.

How Childress Nursing Services supports you

If you decide to try the network gap exception, Childress Nursing Services can help by:

providing the practice and provider info your insurance company requests
helping you describe the service clearly, so the request matches what you need
completing the provider section of the form, if required
helping reduce mistakes that can delay approval
helping you plan timing, so you are not stuck waiting at the last minute

We cannot promise approval. Insurance plans make their own decisions. But we will support you through the process.

Because you deserve options.

If your request is denied

If your request is denied, please do not assume it is the end.

You can ask your insurance company:

“Why was it denied?”
“Can I appeal?”
“What exact documents would make it stronger?”

Sometimes the denial is about missing paperwork, unclear wording, or the insurance company thinking there is an in-network option when that option is not realistic.

Also, some clients choose to:

proceed as out-of-network with upfront payment and request reimbursement, if their plan allows it
plan earlier and try again for the next phase of care
review insurance plan options during open enrollment, if timing allows

A short script you can read on the phone

“Hi, I am calling to ask about a network gap exception, sometimes called a gap exception or single case agreement. I need in-home skilled nursing care, and I cannot find an appropriate in-network option for this service. What is the process for requesting an exception on my plan, and what documents do you need?”

One last note, from Childress Nursing Services

Trying to build a family is already a lot. You should not have to become an insurance expert on top of everything else.

Childress Nursing Services created this guide, because we care about access and fairness. If you found out you are out-of-network through our benefits check email, and you want to explore this option, reach out. We will help you get the right information to your insurance company.

You do not have to figure it out alone.

Next step...

If you already submitted your insurance form and received your Childress Nursing Services benefits check email, reply to that email and tell us:

your insurance company & plan's name
whether they mentioned a gap exception or single case agreement
whether they gave you a form or portal instructions

If you want to see if your insurance plan covers Childress Nursing Services home-based nursing care and have not submitted our health insurance form yet, start here: www.childressnursing.com/insurance

Your Childress Nursing Services' Client Care Coordinator Team!