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

If a Member is having a difficult time finding a network provider that is available to see the Member in a reasonable period of time or that is within a reasonable proximity to the Member, the Member should call the Member Services number or Behavioral Services number on their insurance ID card (some carriers may have a special number for behavioral health services) to seek assistance in finding a network provider.  If the network providers the carrier identifies are unavailable or located too far away, the member may consider requesting an in-network exception. The Q&A below may provide some general background on this process. 

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

A:  New Jersey regulations require an HMO, service corporation or an insurer (collectively “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 or available within a reasonable period of time or within a reasonable distance within the network as described above. In such cases in instances where the Member and/or the Member’s primary care physician have made reasonable efforts to access the services in network and can reasonably document those efforts,  a Member or the Member’s primary care physician may request that the carrier grant what is called an “in-network exception,” where the carrier  is requested to  provide 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 requests may be made by the Primary Care Physician or the Member to the carrier by calling the carrier’s Member Services number or Behavioral Services number(the phone number will be on the  ID Card) or Provider Services if initiated by a provider.   Requests must be made prior to the rendering of the services and granted by the carrier in order to be eligible for the exception.  Documentation, including a summary of efforts that have been made to access the required services in 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 will need to consult with the carrier, but generally a Member will need to show at a minimum 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 has provided adequate documentation of efforts that have been made to access the required services in-network, without success  and (4) despite the carrier’s expeditiously undertaken efforts to secure an in-network provider appointment for the Member within the time frame and distance parameters set forth above,  the carrier has determined that based on its unsuccessful efforts to obtain an appointment for the Member and the documentation submitted by the Member,  there is not a provider in the network within the Member’s geographic  area with the capacity to provide the service within a reasonable time frame as set forth above.

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.

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-emergent services for a person traveling or on vacation and outside of the carrier’s approved service area would not result in eligibility for an in-network exception.

*This is intended as general guidance and not as 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.