If you are running an outpatient clinic, you have probably had this experience. A patient finally finds the right specialist, everyone agrees the care is medically necessary, then the insurer says the clinician is out of network and the whole plan grinds to a halt. That single moment can hurt access, jam your schedule, and load your staff with calls and appeals.
An Out of Network Exception Request is one of the few levers you have in that situation. Handled well, it can protect patients from sudden costs, keep your schedule moving, and prevent your front desk from living on hold with payers.
Solum Health positions itself very clearly in this world, as a unified inbox and AI intake automation platform for outpatient facilities. The platform is specialty ready, integrates with EHR and practice management systems, and focuses on measurable time savings. Understanding exception requests helps you decide when that type of automation should capture and track them, and when a person needs to step in.
From an access perspective, an Out of Network Exception Request is about one thing. Getting a patient to the right care when the network design does not match real world supply. Many outpatient services, especially behavioral health and certain therapies, still have limited in network options in some regions. Studies of out of network claims in large employer plans have shown that patients are exposed to higher cost sharing and surprise bills when they are forced outside the network, which is one reason these exceptions exist in the first place.
For throughput, every unresolved network issue shows up as an empty slot, a pushed start date, or a broken plan of care. When your team has a clear playbook for exception requests, you are less likely to cancel or delay visits while everyone waits for a decision that might have been prepared weeks earlier.
For staff workload, the impact is direct. Exception requests touch referrals, intake, authorizations, and billing. If they are handled ad hoc, each one turns into a mini project. If they are routed and tracked through a central system, for instance a consolidated inbox or automated intake workflow such as the ones described on Solum’s solutions and resources pages, you can cut the rework and make the process feel less chaotic for staff.
At its core, an Out of Network Exception Request is a formal petition to an insurance plan. You are asking the plan to treat a specific out of network provider as if that provider were in network for a given patient and service. If the plan agrees, the patient receives in network level coverage, or something close to it, even though the provider is not contracted.
Plans usually consider these requests when:
Sometimes the approval is paired with what many administrators call a single case agreement. That is a one time arrangement that sets rate and billing terms for that patient’s care.
While each payer has its own rules, the process usually follows a consistent pattern.
You or your clinicians recognize that a patient cannot reasonably receive the needed care from an in network provider. That might be because of geography, wait lists, or clinical requirements that only a few clinicians in your region can meet. Being precise about that gap at the start will help the whole request.
Successful requests tend to include:
This is where a central communication hub earns its keep. If you already use an AI assisted intake and routing tool like the front office automation described on the Solum Health home page, you can pull the relevant messages and documents from a single thread instead of hunting through multiple systems.
Plans may ask you to submit the exception inside a prior authorization portal, on a dedicated form, by secure fax, or through another channel. The details are picky, and they change, so it pays to keep a short internal guide for your most common payers. Your team should know where the form lives, what fields are mandatory, and which documents to attach.
Once the request is in, the plan reviews it. Decisions can arrive within a few days or take several weeks. Some payers pause the clock while they wait for more information, so make sure any requests for clarification go back quickly and in writing. A tracking view inside an intake or authorization queue, something many blog posts on automation now emphasize, can reduce the risk that a follow up request gets buried.
Outcomes generally fall into four groups:
A denial does not mean the request was wrong. It might mean the plan’s directory does not match the reality your staff knows. If you appeal, bring new detail, not just a restatement of the original letter. That can include updated notes, clearer distance or wait time evidence, or a more specific explanation of why the available in network option is not clinically appropriate.
If you want to make Out of Network Exception Requests something your team can manage this month, not next year, think in terms of playbooks and tooling.
First, define who owns each part. Intake and front desk staff can flag patients who might need an exception, but clinical leads should approve the rationale. A revenue cycle lead can watch for denials related to network status so your process improves over time.
Second, use your systems deliberately. A platform that brings calls, texts, email, and portal messages into a single queue, similar to what Solum promotes as a unified front door on its Glossary and blog content, can route payer questions to the right person, store documents in context, and cut duplication. You do not need every feature in the world. You do need one reliable place where your staff can see the status of each request.
Third, script your communication. Patients want to know what this request is, how long it may take, and what their financial exposure is if it is denied. Short, plain language templates can keep those conversations consistent and reduce the emotional load on staff who have to deliver the message.
A few patterns tend to cause trouble.
One is vague documentation. Phrases like “no access” or “too far” rarely persuade. Specific distances, wait times, and clinical reasons carry more weight.
Another is fragmentation. If intake handles the initial request, clinicians handle appeals, and billing handles denials, but no one owns the whole story, your team will repeat work and miss deadlines. A single operational owner and a shared tracking view can prevent that.
A third is silence on the financial side. Even a strong request can be denied. Patients should never find out about that denial after a large out of pocket bill arrives. Build a step into your workflow to notify patients of final decisions in plain language.
What qualifies a patient for an Out of Network Exception Request?
A patient typically qualifies when there is no clinically appropriate in network option within a reasonable time frame or distance, or when changing to an in network provider would disrupt an established course of treatment. Plans expect specific evidence, not just preference.
How long does an exception request usually take?
Timelines vary by plan. Some decisions arrive within a week, others take several weeks, especially if the plan requests additional information. Submitting a complete packet the first time and tracking follow up questions can shorten the overall process.
Is an exception the same as a single case agreement?
They are related but not identical. An exception is the payer’s decision to cover an out of network provider at in network benefit levels for a specific situation. A single case agreement is a temporary arrangement that sets the rate and terms for that care.
Can an exception request be denied?
Yes. Denials are common when the plan believes an in network provider can meet the need or when documentation does not clearly show medical necessity and access barriers. In many cases, a structured appeal with better evidence has a higher chance of success.
Does an approval always guarantee in network rates?
Most approvals move coverage close to in network cost sharing, but you should never assume. Read the decision carefully, confirm visit limits and cost sharing, and make sure your team communicates the details to the patient before care continues.
If you want to move fast, here is a practical sequence you can start now.
Out of Network Exception Requests will never be simple, but with a clear process and the right infrastructure, they do not have to paralyze your schedule or your staff. The more you treat them as a defined operational flow, supported by automation where it makes sense and by human judgment where it matters most, the more they will work for your clinic instead of against it.
