The Three CMS Network Adequacy
Exception Types, Explained
When a county can't meet CMS adequacy standards, three resolution pathways exist: Access Exception, Geographic Exception, and Service Area Reduction. Each has distinct eligibility criteria, documentation requirements, and consequences.
Exception Types
Select an Exception Type to Explore
When providers exist but won't contract
An Access Exception applies when providers exist in a county but are unwilling to contract with your plan despite documented, good faith outreach. CMS grants this exception when a plan demonstrates that no willing provider can be found after a sustained recruitment effort.
When It Applies
- Providers in the county are declining to contract at any reasonable rate
- All providers in the specialty are part of a competing plan's exclusive network
- Providers have retired or are otherwise unavailable to new contracts
- The county has providers but they have closed panels to Medicare patients
Required Documentation
- Chronological outreach log showing minimum four contact attempts per targeted provider
- Written or verbal declination records for each provider with stated reason
- Rate offer documentation showing offers within a reasonable market range
- Narrative explaining the market conditions preventing successful contracting
- Supporting data: HRSA shortage designations, workforce data, competing plan contracts
Common Denial Reasons
- Fewer than four documented outreach attempts per provider
- No documentation of declination reasons — verbal refusals must be logged
- Rate offers significantly below regional benchmarks (CMS treats this as bad faith)
- Provider contacted once by email only — CMS expects multi-channel outreach
HPMS Filing Notes
Filed as an 'Access Exception Request' in the HPMS network adequacy module. CMS reviews within the standard review cycle and may request additional documentation. Approval is not automatic — CMS evaluates whether the good faith standard was met.
Side-by-Side Comparison
Choosing the Right Exception Pathway
| Criterion | Access Exception | Geographic (GEO) | Service Area Reduction |
|---|---|---|---|
| Provider exists in county | Yes — but won't contract | No — absent from area | Doesn't apply |
| Good faith outreach required | Yes — 4 attempts min | Usually not needed | Not required |
| CMS prior approval | Yes | Yes (sometimes auto) | Yes — required |
| Member impact | None if approved | None if approved | Members must be notified |
| PBP change required | No | No | Yes |
| Preferred by CMS | Acceptable | Acceptable | Last resort |
| Available post-enrollment freeze | Usually no | Sometimes | No |
Filing Process
How to File an Exception Request in HPMS
Identify the gap type
Determine whether the deficiency is an access issue (providers exist, won't contract) or geographic issue (no providers in range). This determines which exception applies.
Compile the evidence package
Build the documentation: outreach logs, declination records, HRSA data, shortage designations, or geographic search results — depending on exception type.
Draft the exception narrative
CMS expects a written explanation of why the standard cannot be met. Address market conditions, outreach efforts, and provider availability. Be specific — vague narratives are rejected.
Submit via HPMS
File the exception request in the HPMS network adequacy module within the deficiency response window (30 days for deficiency notices; at initial submission for pre-emptive requests).
Respond to CMS follow-up
CMS reviewers often request additional documentation. Respond promptly — delays can push the review past the exception window.
Implement alternative access plan
For approved exceptions, document the alternative access pathway for affected members (telehealth, out-of-area referral, transportation coordination). CMS expects this even when the exception is approved.
Blueprint Platform
Know Which Counties Need Exceptions Before You Submit
Blueprint's gap analysis flags exception-eligible counties before your initial submission — so you can file pre-emptive exception requests with the evidence already compiled, rather than scrambling after a deficiency notice.
FAQ
Exception Request Questions
Related Resources
Good Faith Effort Guide
4-attempt outreach standard and documentation requirements
Deficiency Response Guide
30-day response window and corrective action process
Gap Analysis Tool
Identify exception-eligible counties before submission
Access Exception Deep Dive
Detailed article on the Access Exception filing process