How to Request a CMS Network Adequacy Exception (and Why Most Fail)

To request a Medicare Advantage network adequacy exception, you file CMS's current exception request template in HPMS for one county and one specialty, and you prove two things under 42 CFR 422.116(f). First, the providers you would need to meet the time and distance standard are not actually available. Second, the providers you did contract with are currently available and accessible to most enrollees, consistent with the local pattern of care. Inability to contract is not a valid reason. Neither are your own internal standards. Everything else in the file is evidence for those two points.

That is the rule. The rest of this piece is about why so many requests still fail.

Our view, after 30 years between us of building networks: most exception requests fail because they are negotiation stories dressed up as supply problems. The pattern is familiar. An orthopedic group in the county seat wants a rate the plan won't pay, so the request says the provider is unavailable. CMS reads that request next to its own Provider Supply file and its own claims data, finds the group still practicing at the same address and still billing Medicare, and denies it. Nobody lied. The file simply answered a question CMS never asked, which is whether the supply of care in that county is different from what CMS's data shows.

What 422.116(f) actually says, in plain words

The regulation opens two doors. A request has to walk through one of them.

The supply door, (f)(1)(i). Both halves have to be true at once. (A) Certain providers or facilities "are not available" in that county and specialty, as shown in the Provider Supply file. (B) The plan has contracted with other providers, possibly beyond the time and distance standard, who are "currently available and accessible to most enrollees, consistent with the local pattern of care." Half A without half B is a gap. Half B without half A is a preference.

The facility-based I-SNP door, (f)(1)(ii). A facility-based institutional SNP can ask for an exception when it cannot contract with certain specialty types because of the way its enrollees receive care, or when it provides adequate access through additional telehealth benefits. There are strings attached, covered below.

Then (f)(2) tells you how CMS weighs a request. CMS considers whether current access is different from what the HSD Reference File and Provider Supply file show for the year; whether other factors under 422.112(a)(10)(v) demonstrate access "consistent with or better than the original Medicare pattern of care"; whether approval "is in the best interests of beneficiaries"; and, for facility-based I-SNPs, whether the required evidence is there.

Put together, CMS is not asking whether you tried hard. It is asking whether its own picture of supply is wrong, and whether your members will get care the way people in that county already do under Original Medicare. The December 2024 network adequacy guidance, still the edition posted on CMS's application page, is blunt about the standard: the plan must provide "conclusive evidence" that it can't meet the criteria because supply has changed, and must show its contracted network is "consistent with or better than the Original Medicare pattern of care."

The rationales CMS accepts, and the two it will not

The guidance lists valid rationales and says the list is "not limited to" them. Write to the list anyway, because each item is something a reviewer can check against a public or CMS source:

• the provider is no longer practicing (deceased or retired);
• the provider does not contract with any organization, or contracts exclusively with another one;
• the provider is not practicing at the address in the supply file;
• the provider is not practicing in the specialty the supply file shows;
• the provider has opted out of Medicare;
• the provider is on the OIG List of Excluded Individuals and Entities;
• enrollees are served by Original Medicare telehealth or mobile providers;
• specific community patterns of care.

Two more are accepted only with "substantial and credible evidence": the provider may cause beneficiary harm, or the provider is inappropriately credentialed under 42 CFR 422.204. Those go in as "Other," with the explanation in the Additional Notes on Reason for Not Contracting field. If you use either one, the evidence carries all the weight. A general quality concern will read as an internal standard.

And internal standards are out. The excluded reasons are short and absolute. "Inability to contract" is not valid, because the non-interference clause in Social Security Act section 1854(a)(6) keeps CMS out of plan and provider negotiations. CMS will not referee your rate dispute, so it will not excuse you from one either. The plan's "own internal standards" are also not a valid reason to reject a qualified provider.

We would put it more bluntly than CMS does. If the honest answer to "why isn't this provider in network?" contains the word rate, you do not have an exception. You have a contracting decision. You are allowed to make it, and sometimes it is the right call, but then the move is to pay, to recruit someone else, or to drop the county. Not to file.

What the draft says	How it is likely to read	What to do instead
Provider declined our offer	Inability to contract. Not valid.	Use it only if the provider contracts with no MA organization, or exclusively with another. Otherwise keep negotiating or recruit.
Does not meet our credentialing criteria	Internal standards. Not valid.	Use "Other" only with substantial and credible evidence of harm or inappropriate credentialing under 422.204.
Still in negotiation	A placeholder	CMS's 2017 template listed "In the process of negotiating" and flagged it as not a valid rationale. Finish the contract or plan for the gap.
Retired (nothing attached)	Unsupported	Attach a license lookup, a Medicare opt-out or enrollment check, or a dated outreach note.

Pattern of care is where good requests are won

Half B of the supply door is where the real argument lives, and most drafts underinvest in it. The guidance says pattern-of-care evidence can be internal claims data showing the current pattern of care in that county and specialty, or a detailed explanation. Either way, the plan must compare the closer non-contracted providers against the farther contracted ones.

That comparison is the whole point. If your claims show members in a frontier county already drive past the closer, non-contracted practice to reach the regional center you do contract with, show it. Show the utilization. Show where the referrals go. Show that the contracted providers are taking new patients and can be reached. A reviewer should be able to look at your comparison and conclude that contracting with the closer provider would not change where people actually get care.

Assume CMS will check. CMS's 2017 guidance said it used the Integrated Data Repository to validate pattern-of-care claims, and the current regulation says the Provider Supply file is built partly from IDR claims data and may be updated from exception-request validation. A pattern-of-care story that CMS's claims don't support is worse than no story, because it tells the reviewer your other assertions may be soft too.

One more thing people miss. The guidance says the criteria "are not restricted by state or county boundaries." A member's real pattern of care often crosses a county line or a state line. So should your evidence.

Why CMS denied 58%, and what the top reason tells you

The best public numbers on outcomes come from MedPAC's June 2024 report to Congress. In 2021, CMS denied 259 of the 448 exception requests it reviewed, or 58%. HMOs had two-thirds of their requests denied. PPOs had 35% denied.

The most common denial reason is the useful part. According to MedPAC, it was that CMS found providers within the criteria that the plan "failed to include" on the exception request or HSD tables.

Sit with that. The leading cause of denial was not a weak argument or a missing signature. It was an incomplete census. Somewhere inside the time and distance standard there was a provider the plan hadn't accounted for, either a non-contracted provider with no disposition or someone who belonged on the HSD tables and wasn't there. The reviewer found them. The plan didn't.

That squares with what CMS says about its own data. The guidance warns that the Provider Supply file "may not be a complete depiction" of supply and that plans "should not rely solely on the supply file." The file can list providers who are gone, which is what your rationales are for. It can also miss providers who are very much there, and those sink requests. A good exception request is mostly a good census with an argument on top. (The same census gap explains a lot of networks that pass internally and fail at CMS.)

MedPAC also noted that CMS has never imposed intermediate sanctions or civil money penalties for network adequacy noncompliance. "However, new applications have been denied on this basis." For an applicant, a denied exception is not a warning letter. It can be the county.

Mechanics that sink otherwise sound files

The process rules are dull. They still decide outcomes. All of these come from the December 2024 guidance unless noted.

Use the current template. It lives in HPMS under Monitoring, Network Management, Documentation, Templates, and plans "must use the current exception request template." It is not public, so don't rebuild last year's version from memory.

Separate PDFs, one zip. The exception forms and the supporting documents (maps, screenshots, letters) go up as separate PDFs inside a single zip file. Non-contracted providers that don't fit on the form go on the MA Exception Template Non-Contracted Providers Overflow template, which replaced the older method of attaching a second "Part 2" PDF. The December 2023 guidance showed file names built from contract, SSA county code and specialty code (HXXXX_12345_001); confirm the current convention in the template instructions.

Resubmit every approved exception, every time. Plans must resubmit all previously approved exceptions whenever CMS requests an HSD upload. An approval is not a permanent waiver. It is a finding about supply at a point in time, and supply moves: the retired cardiologist's practice may have a new owner. Before each upload, re-verify every approved exception as if it were new.

Know your last chance. For applicants, the final upload opportunity is the response to CMS's Notice of Intent to Deny, and the regulation gives you 10 days to respond (42 CFR 422.502(c)(2)(ii)). Ten days is not enough time to build a census. We lay out the full application calendar in our service area expansion timeline.

Three things that look like exceptions and aren't

The facility-based I-SNP prong comes with a condition. The CY2025 rule added the I-SNP exception in April 2024, and because of a drafting error in the amendment, it only made it into the regulation text after a correction published August 6, 2024. It lets a facility-based I-SNP get an exception when it cannot contract with certain specialty types because of how its enrollees receive care, or when it provides adequate access through additional telehealth benefits. The catch sits in (f)(3): an organization that receives this exception may offer only facility-based I-SNPs under that contract. If the contract carries other plan types, this door is closed.

A partial county is a different request. Asking to serve only part of a county falls under the county integrity rule in 42 CFR 422.2, not under 422.116(f). It must be necessary, nondiscriminatory and in beneficiaries' best interests, it uses the Partial County Justification template, and "inability to establish economically viable contracts" is not an acceptable reason, per the guidance and the CY2027 Part C application. Plans sometimes reach for a partial county when an exception is failing. That is the same negotiation story in a different costume, and it gets the same answer.

The pattern-of-care exception is not law. The CY2027 proposed rule (90 FR 54894, November 28, 2025) floated a standalone pattern-of-care exception under 422.116(f)(1) and asked for comment on simplifying the exception request process. The CY2027 final rule, published April 6, 2026, did not amend 422.116 at all. If you read somewhere that plans can now get an exception on pattern of care alone, that is wrong. As of this writing, you are working under the same (f) text described above, where pattern of care is half of the supply test, not a door of its own.

Evidence checklist for one county and one specialty

Run this for each failing county and specialty pair. Our rule of thumb is to start it the day the automated criteria check fails, not the week before the upload.

1. Confirm the failure precisely. Pull the ACC result and the ZIP Code Report for Failed Counties. Note whether you failed the minimum count, the time and distance percentage, or both, and which threshold applies: 85% of beneficiaries in Micro, Rural and CEAC counties, 90% in Large Metro and Metro. If the two tests are new to you, start with how CMS scores network adequacy.
2. Pull the Provider Supply file for the specialty in the failing county and every adjacent county, across state lines where relevant.
3. Add the providers the supply file misses. Check state licensing boards, NPPES, hospital medical staff lists and your own claims for anyone practicing inside the standard. This is the step that answers MedPAC's top denial reason.
4. Give every provider inside the standard a disposition. Contracted, in recruitment, or not available for a listed reason. No blanks.
5. Attach dated proof for each "not available" row. A license lookup, an OIG exclusion search, a Medicare opt-out check, a dated call note, a screenshot of the practice website, or a letter saying the provider contracts with no MA plan or only with another one.
6. Remove every rate story. If a row's real reason is price or a stalled negotiation, pull it out of the exception and send it back to contracting.
7. Build the pattern-of-care comparison. Claims showing where members in the county get this specialty today, set against the closer non-contracted providers and the farther contracted ones.
8. Show the contracted alternatives are real. Addresses, distances, new-patient status, hours. Include telehealth or mobile providers if they are part of the access story.
9. Write the narrative to the (f)(2) factors, in order: how supply differs from CMS's files, why access matches or beats the Original Medicare pattern of care, and why approval is in beneficiaries' best interests.
10. Package it. Current HPMS template, separate PDFs, the overflow template if needed, one zip, plus every previously approved exception on the contract.
11. Have someone outside contracting read it cold and answer one question: is this a supply problem or a negotiation story?

Write the file CMS would write about you

The requests that hold up read almost as if CMS wrote them. They start from CMS's own supply file, account for every provider inside the standard, and put the plan's claims next to CMS's. The ones that fail start from the plan's contracting history and work outward. Same county, same specialty, a different question.

If the evidence isn't there, the exception isn't either. The honest options are recruiting, a better offer or a smaller service area, and every one of them is easier in June than in the ten days after a NOID.

Blueprint keeps the recruiting pipeline, follow-up and adequacy scoring on the same provider records, so the outreach trail an exception depends on isn't scattered across inboxes. It won't write the exception for you. You can see a gap and test recruit what-ifs on sample data at the network map, or score your build with the free build scorecard.