Good-Faith Effort Documentation: How to Protect Your Adequacy Filing in Rural Counties

What Is a Good-Faith Effort Waiver?

CMS recognizes that certain counties — particularly rural counties with sparse provider populations — may not have enough providers to allow any health plan to meet the standard time-and-distance thresholds. For these situations, CMS accepts a "good-faith effort" exception, also called a provider shortage exception or access exception.

A good-faith effort exception does not eliminate the adequacy requirement. It documents that the plan has made genuine, sustained efforts to recruit providers to the county, that no providers are available within threshold despite those efforts, and that the shortage is a market-level reality rather than a plan-specific contracting failure.

When Does Good-Faith Effort Apply?

Good-faith effort documentation is appropriate when:

• The county has fewer providers of the required specialty than the minimum CMS requires (typically 2), and those providers are not participating in your network
• You have conducted documented outreach to all available providers in the county and in adjacent counties, and providers are either unavailable, non-accepting, or declined your offer
• The shortage is consistent across plans in the area — it is a market access problem, not a competitive contracting failure

Good-faith effort is not a fallback for counties where providers exist but the plan chose not to pursue them aggressively, or where the plan's contracted rates were significantly below market and drove provider refusals.

The Four Components of Adequate Documentation

CMS expects good-faith effort documentation to include four elements:

1. Provider Inventory

A complete list of all providers of the relevant specialty in the county, sourced from NPPES or a comparable registry. For each provider, document: NPI, practice address, specialty, and current network status (in-network with which plans, if known).

2. Outreach Log

A chronological record of outreach attempts to each provider in the inventory. For each attempt, document: date, method (phone, mail, email, in-person), person contacted, and outcome. CMS expects a minimum of three contact attempts per provider over a defined outreach period before concluding a provider is unavailable.

3. Adjacent County Analysis

If providers in the deficient county are unavailable, document that you evaluated adjacent counties for providers whose geographic proximity places them within a reasonable distance of members in the deficient county — even if technically outside the county boundary.

4. Market Shortage Certification

A narrative statement certifying that the shortage is a market-level issue, typically supported by data showing that other plans in the county also lack in-network providers of the specialty. CMS HPMS data on participating plan provider networks can support this certification.

Timeline: When to Start Documentation

Good-faith effort documentation must be contemporaneous — it cannot be reconstructed after the fact. Network ops teams should initiate outreach logging for shortage counties no later than 6 months before their adequacy submission date. Outreach that begins 2 weeks before submission will not be credible documentation of a sustained effort.

Blueprint's pipeline tracker flags counties approaching threshold violations early in the build cycle, giving teams the time to either recruit a provider or begin proper good-faith documentation.

After the Filing: CMS Review of Exception Claims

CMS reviews good-faith effort claims during its post-submission adequacy review. Plans that submitted exception claims for the same county in multiple consecutive benefit years without new outreach documentation face heightened scrutiny — CMS may request an in-person review or impose conditions on the plan's approval.

The best practice is to use good-faith documentation as a bridge measure while actively pursuing a telehealth solution, a contracted provider in an adjacent county with extended-travel agreements, or other access alternatives that resolve the underlying gap.