Bay Area Neuropsychiatry, free templates for requesting in-network coverage of specialist care your insurer's network cannot provide.
How to use these letters:
Choose the letter that matches the type of care you are seeking. Replace every highlighted field (shown in gold) with your own information. You can print the letter and mail it, or copy the text into an email to your insurance company. Send it to the address on the back of your insurance card, or ask your insurer for the correct address for network gap exception requests. Keep a copy of everything you send, and document the date you mailed or submitted it. Background on the process is on our insurance page.
[Insurance Company Name] [Insurance Company Address] [City, State, ZIP]
Re: Request for Network Gap Exception / Out-of-Network Override Member: [Your Full Name] Member ID: [Your Member ID Number] Group Number: [Your Group Number, if applicable]
Dear [Insurance Company Name],
I am writing to request a network gap exception (also known as a network deficiency request or out-of-network override) so that my psychiatric care with a physician at Bay Area Neuropsychiatry may be covered at in-network benefit levels.
I have been diagnosed with [your diagnosis, e.g., Major Depressive Disorder, ADHD, OCD, PTSD, Bipolar Disorder, Traumatic Brain Injury, Functional Neurological Disorder, etc.] and require evaluation and treatment by a psychiatrist with subspecialty training in Behavioral Neurology & Neuropsychiatry.
Behavioral Neurology and Neuropsychiatry is a recognized subspecialty certified by the United Council for Neurologic Subspecialties (UCNS). Since 2006, only 371 physicians in the United States have completed a UCNS-accredited fellowship in this subspecialty, and only about 120 of them trained as psychiatrists; a fraction of those are actively accepting new outpatient referrals. I believe your network does not currently include a physician with equivalent qualifications who is available to see me.
The out-of-network physician I am requesting coverage for is:
Physician: [Dr. Shafi Lodhi, MD / Dr. Rohan Patel, DO]
NPI: [1922539337 / 1851929731]
Practice: Bay Area Neuropsychiatry (Lodhi Medical Group, PC)
Tax ID: 99-1356314 · Group NPI: 1689439911
Address: 870 Market Street, Suite 341, San Francisco, CA 94102
Phone: (650) 248-2467 · Fax: (855) 452-6817
Subspecialties: Psychiatry, Behavioral Neurology & Neuropsychiatry, Consultation-Liaison Psychiatry, Perinatal Psychiatry, Forensic Psychiatry
CPT Codes: 90792, 99205, 99215, 99214, 90833, 90836, 90837
I am formally requesting that you authorize coverage for my care with this physician at in-network benefit levels, given the demonstrated deficiency in your network for this type of subspecialist.
Legal Basis for This Request
Both California and federal law support this request. Under the federal Mental Health Parity and Addiction Equity Act (MHPAEA), health plans may not impose greater barriers to mental health care than to medical and surgical care, including through the adequacy of provider networks.
California law provides additional protections. For plans regulated by the Department of Managed Health Care (DMHC), Health and Safety Code Section 1374.72 and the implementing regulation at 28 CCR Section 1300.67.2.2 require that if an enrollee cannot obtain a covered service within the plan's network under applicable geographic and timely access standards, the plan must arrange for that service from an out-of-network provider, with the enrollee paying no more than in-network cost-sharing amounts. For plans regulated by the California Department of Insurance (CDI), 10 CCR Section 2240.1 establishes parallel network adequacy requirements.
Additionally, SB 855 (Health & Safety Code Section 1374.72, as amended) requires all commercial health plans to cover the full range of mental health and substance use disorder conditions at parity with medical and surgical benefits, and to arrange and pay for out-of-network services when medically necessary care is unavailable in-network. SB 221 requires that non-urgent appointments with specialist physicians be available within 15 business days of the request.
I respectfully request a written response to this request within 30 calendar days, consistent with California's grievance resolution timelines. If this request is denied, I ask that you provide a written explanation of the basis for the denial, including the names and contact information of in-network physicians with equivalent subspecialty qualifications who are currently accepting new patients and available to see me within the timely access standards required by California law.
Please be advised that if this request is denied and I believe the denial is not justified, I intend to file a complaint with the appropriate California regulatory agency, the Department of Managed Health Care (DMHC) Help Center at 1-888-466-2219 or the California Department of Insurance (CDI) at 1-800-927-4357, and to request an Independent Medical Review if applicable.
CC: [Your Primary Care Provider, if HMO and referral obtained] Enclosures (if applicable): supporting clinical records
[Insurance Company Name] [Insurance Company Address] [City, State, ZIP]
Re: Request for Network Gap Exception / Out-of-Network Override Member: [Your Full Name] Member ID: [Your Member ID Number] Group Number: [Your Group Number, if applicable]
Dear [Insurance Company Name],
I am writing to request a network gap exception (also known as a network deficiency request or out-of-network override) so that my psychiatric care with a physician at Bay Area Neuropsychiatry may be covered at in-network benefit levels.
I have been diagnosed with [your diagnosis, e.g., perinatal depression, perinatal anxiety, postpartum depression, premenstrual dysphoric disorder, perimenopausal mood disorder, treatment-resistant depression, a mood or anxiety disorder requiring management during pregnancy or breastfeeding, etc.] and require care from a psychiatrist with subspecialty expertise in [perinatal psychiatry / reproductive psychiatry / women's mental health / perimenopause-related psychiatric care].
Dr. Staley is fellowship-trained in consultation-liaison psychiatry, an ABPN-recognized subspecialty that requires completion of an ACGME-accredited fellowship beyond general psychiatry residency. Consultation-liaison psychiatrists are trained to evaluate and treat psychiatric conditions in medically complex patients, including those whose care spans multiple medical specialties. Within this already limited subspecialty, Dr. Staley has developed further expertise in perinatal psychiatry, reproductive mental health, and perimenopausal psychiatric care. This combination of formal subspecialty training and clinical focus is exceptionally rare. According to the Maternal Mental Health Leadership Alliance, fewer than 500 psychiatrists in the entire United States are trained in reproductive mental health, for the roughly 800,000 women who experience a maternal mental health complication each year. Three in four of those women do not receive treatment, in large part because qualified specialists are unavailable. Psychiatrists with expertise in perimenopausal mood disorders are rarer still, as no formal fellowship pathway exists for this area of practice. I believe your network does not currently include a physician with equivalent qualifications who is available to see me.
The out-of-network physician I am requesting coverage for is:
Physician: Sarah Staley, MD
NPI: 1275038275
Practice: Bay Area Neuropsychiatry (Lodhi Medical Group, PC)
Tax ID: 99-1356314 · Group NPI: 1689439911
Address: 870 Market Street, Suite 341, San Francisco, CA 94102
Phone: (650) 248-2467 · Fax: (855) 452-6817
Specialties: Psychiatry; Consultation-Liaison Psychiatry (ABPN-certified, ACGME-accredited fellowship); Perinatal Psychiatry; Reproductive Psychiatry; Perimenopausal Psychiatric Care; Women's Mental Health
CPT Codes: 90792, 99205, 99215, 99214, 90833, 90836, 90837
I am formally requesting that you authorize coverage for my care with this physician at in-network benefit levels, given the demonstrated deficiency in your network for this type of subspecialist.
Legal Basis for This Request
Both California and federal law support this request. Under the federal Mental Health Parity and Addiction Equity Act (MHPAEA), health plans may not impose greater barriers to mental health care than to medical and surgical care, including through the adequacy of provider networks.
California law provides additional protections. For plans regulated by the Department of Managed Health Care (DMHC), Health and Safety Code Section 1374.72 and the implementing regulation at 28 CCR Section 1300.67.2.2 require that if an enrollee cannot obtain a covered service within the plan's network under applicable geographic and timely access standards, the plan must arrange for that service from an out-of-network provider, with the enrollee paying no more than in-network cost-sharing amounts. For plans regulated by the California Department of Insurance (CDI), 10 CCR Section 2240.1 establishes parallel network adequacy requirements.
Additionally, SB 855 (Health & Safety Code Section 1374.72, as amended) requires all commercial health plans to cover the full range of mental health and substance use disorder conditions at parity with medical and surgical benefits, and to arrange and pay for out-of-network services when medically necessary care is unavailable in-network. SB 221 requires that non-urgent appointments with specialist physicians be available within 15 business days of the request.
I respectfully request a written response to this request within 30 calendar days, consistent with California's grievance resolution timelines. If this request is denied, I ask that you provide a written explanation of the basis for the denial, including the names and contact information of in-network physicians with equivalent subspecialty qualifications who are currently accepting new patients and available to see me within the timely access standards required by California law.
Please be advised that if this request is denied and I believe the denial is not justified, I intend to file a complaint with the appropriate California regulatory agency, the Department of Managed Health Care (DMHC) Help Center at 1-888-466-2219 or the California Department of Insurance (CDI) at 1-800-927-4357, and to request an Independent Medical Review if applicable.
CC: [Your Primary Care Provider, if HMO and referral obtained] Enclosures (if applicable): supporting clinical records
These templates are provided as a courtesy and do not constitute legal advice. Insurer processes vary; your plan may use its own form. Questions? Call our office at (650) 248-2467. We are happy to help you complete the request.
