Network Gap Exception Request Form

PCA-1-24-02318-UHN-FM_07312024

Network Gap Exception Request Form instructions

Step 1: Submit a prior authorization request

Submit a prior authorization request online on the UnitedHealthcare Provider Portal

or by contacting Provider Services.

• Online —

– Go to UHCprovider.com and click Sign In at the top-right corner

– Enter your One Healthcare ID and password

• If you don’t have a One Healthcare ID, visit UHCprovider.com/access to get started

– In the menu, select Prior Authorizations

• Provider Services — Chat with a live advocate 7 a.m.–7 p.m. CT from the

UnitedHealthcare Provider Portal

You will be assigned a service reference (case) number when you submit your online prior

authorization request. Provider Services will give you the service reference number if you

chat. You must include the service reference number on the Network Gap Exception Form.

Questions?

Connect with us through

chat 24/7 in the

UnitedHealthcare

Provider Portal.

If you have issues

with the portal, find chat

options and contact

information, visit

UHCprovider.com/contactus.

You can request a network gap exception when there aren’t enough health care

professionals in a local area or in a specific specialty.

Step 2: Complete the Network Gap Exception

Request Form

Please complete the required fields:

• Service reference number

• All member information, including member ID and

date of birth

• All health care professional information, including

the in-network referring health care professional.

The in-network referring health care professional is

typically the member’s primary care provider (PCP)

but can also be any in-network health care professional

who refers the member.

• If a specialty request, list the specific clinical reason

for the network exception

– If you are requesting specialized equipment,

include the make/model information

– If you are requesting specialized training or

techniques, you must provide details for what

training, treatment, technique, etc., you are performing

Step 3: Submit the Network Gap Exception Form and clinical documentation

• Online: Upload clinical documentation on the portal in the prior authorization section

(e.g., clinical history/notes, diagnostic testing and conservative treatment)

• Fax: Print the form and your clinical documentation, then fax it to the number

Provider Services gives you if you chat for a prior authorization

PCA-1-24-02318-UHN-FM_07312024

Network Gap Exception Request Form instructions

Instructions:

1. Complete this form for all commercial network exception gap requests

2. A prior authorization case must be entered prior to form submission

Service reference number (prior authorization case number):

Member information

Member name (person being treated) Member ID number Date of birth (mm/dd/yyyy)

Address City State/ZIP code

Home/cell phone number Work phone number

Subscriber name Member’s relationship to subscriber

Self Dependent Spouse Other

In-network referring physician information

Network referring physician NPI or Tax ID number (TIN) Phone number

Address City State/ZIP code

Fax number Reason for referral

Out-of-network physician information

Out-of-network physician/specialist

NPI or Tax ID number (TIN) Phone number

Address City

State/ZIP code Fax number

Servicing facility address (if different than above)

City ZIP code

Out-of-network facility information

Out-of-network facility (out-of-network

facility exception requests only)

NPI or Tax ID number (TIN) Phone number

Address City State/ZIP code

Reason for out-of-network facility request [if specialized equipment is the reason for the request,

please include the specific equipment (name/brand/model/etc.)]

Applicable clinical information

Please select:

New patient Existing patient Other

If Other selected, please explain:

Has a gap exception previously been granted?

Yes No Unknown

If Yes, please explain and dates approved:

Has a gap exception previously been approved for a

family member?

Yes No Unknown

If Yes, please explain and dates approved:

Out-of-network physician information

Member diagnosis:

Expected date(s) of service/expected length of treatment:

Service(s) requested (include CPT

codes and visits/units when applicable):

Reason for gap exception request:

Please attach applicable clinical notes for review

PCA-1-24-02318-UHN-FM_07312024

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