How to Advocate for Insurance Coverage for an Out-of-Network Provider
Written by: Elizabeth Solomon-Loyola, PsyD
As a provider, I understand that navigating insurance coverage can be challenging. Patients often find the right specialist for therapy, only to discover that their insurance won’t cover the visit because the provider is "out of network." This can be frustrating, especially when no in-network provider offers the same level of care, or skills needed. Fortunately, there is a process for requesting a "network exception" or "single-case agreement" as it’s called, which may allow an out-of-network provider to be covered as if they were in-network.
9 steps to self-advocate for therapy coverage with insurance companies:
Please take some time to go through this, as it’s rather complicated.
1. Understand Your Insurance Policy
Before contacting the insurance company, patients should review their policy. Important details to look for include:
Whether the plan has any out-of-network benefits.
If exceptions are ever allowed.
What circumstances might qualify for an exception.
Many insurance plans allow for network exceptions if no in-network provider has the necessary expertise, or if care would be delayed due to availability issues. Understanding these details will help build a strong case.
2. Call the Insurance Company
Patients should call the customer service number on their insurance card to ask about network exceptions.
Questions to ask:
Do you offer out-of-network exceptions?
What is the process to request one?
What documentation is required?
How long does it take to process the request?
It’s helpful for patients to take notes, including the names of representatives they speak with and the dates of conversations. If the representative is efficient, effective, and knowledgeable, also ask if there is a direct line to call them, so you can avoid the usual telephone tree with any follow-up calls. A direct line is often not available, but it’s worth asking, especially if you’ve reached a supervisor in the effort.
3. Document In-Network Provider Availability
Insurance companies often require proof that an in-network provider cannot meet the patient’s needs before granting an exception. Patients should keep detailed records of their attempts to find an in-network provider, including:
The names of in-network providers contacted.
Dates and times of calls or appointment requests.
Reasons they were not suitable (e.g., fully booked, do not treat the specific diagnosis, do not work with the patient’s age group, lack the necessary specialization, etc.).
This documentation helps demonstrate why an out-of-network provider is the most appropriate, even necessary, option.
4. Gather Supporting Evidence
A strong case requires persuasive evidence.
Patients should collect the following information:
Medical records demonstrating why this specific provider is necessary. In other words, your child’s needs/diagnosis meet the provider’s skills, experience, therapeutic approach.
Research or medical guidelines supporting the suggested treatment plan.
A list of in-network providers with reasons they are not suitable.
Any past approvals of similar cases, if available.
For rare conditions or specialized treatments, including published medical research can help strengthen the argument.
5. Provide Strong Justifications
To get an exception approved, patients need to clearly explain why an in-network provider is not sufficient. Here are a few examples:
A 10-year-old autistic child with a severe needle phobia: The child requires a therapist with expertise in both autism and phobia treatment. A provider who only specializes in one area will not be effective, making it critical to see an out-of-network provider with dual expertise.
A patient with a rare neurological disorder: The only in-network providers may lack experience in the latest treatment protocols. An out-of-network specialist who has published research on the condition, or developed expertise with up-to-date treatments that are evidence-based, may be the best and only viable option.
A person recovering from a traumatic brain injury who needs a specific rehabilitation approach: If in-network providers do not offer the necessary treatment method, the patient can argue that switching to a provider with the right expertise is essential for recovery.
Providing detailed examples like these can help demonstrate medical necessity and make a stronger case for approval. The out-of-network provider you’re trying to see can perhaps provide some guidance for steps 4 and 5.
6. Write a Letter to the Insurance Company
Patients should submit a formal request for an out-of-network exception.
The letter should include:
The patient’s name, insurance ID number, and contact info.
The provider’s name, contact information, degrees/certifications, and years of experience.
An explanation of why this provider is necessary.
A request for an out-of-network exception with specific parameters, such as weekly sessions for a number of weeks or months.
A request for a written response within a specific timeframe.
Sending the letter via certified mail ensures proof of receipt by the insurance company (so they can’t claim they never received it).
7. Follow Up Regularly
Patients should follow up with the insurance company to check the status of their request and ask:
Has my request been reviewed?
Do you need additional information?
When can I expect a decision?
If no response is received within the expected timeframe, patients can request to speak with a supervisor and document all interactions.
8. File an Appeal If Denied
If the request is denied, patients can appeal the decision. Most insurance companies have an appeal process, required by state law. Patients should request the denial reason in writing and gather additional supporting evidence to strengthen their case. Strategies include:
Providing additional medical documentation.
Highlighting similar cases that were approved.
Contacting their state’s insurance department if the denial seems unreasonable. In California, this is the Department of Managed Care in Sacramento.
9. Seek Additional Help If Needed
If navigating the process becomes overwhelming, patients can seek assistance from hospital patient advocates, legal aid groups, or insurance specialists who handle appeals. Some states have consumer protection offices that can provide guidance.
The Importance of Advocacy
As a provider, I’ve seen how important, even essential, it is for patients to advocate for the care they need. While the process can be complex, staying organized and persistent can improve the chances of getting an exception approved. Understanding the insurance process, gathering the right documentation, and following up regularly can make a meaningful difference in accessing necessary care.
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