How to File a CMS Network Adequacy Access Exception: A Step-by-Step Guide

What an Access Exception Is and When It Applies

A CMS network adequacy access exception is a formal request that a Medicare Advantage plan submits through HPMS to explain why it cannot meet the time-and-distance standard for a given provider type in a given county — and to demonstrate that it has made a good faith effort to establish in-network access and has arranged alternative access for affected members. Access exceptions are not waivers of the adequacy requirement; they are an acknowledgment that in certain geographic or specialty contexts, full compliance is not achievable and CMS needs to understand why.

The two situations that most commonly justify exception requests are: (1) geographic shortage, where the supply of providers in the specialty simply does not exist within the T&D standard in that county, and (2) provider unwillingness to contract, where providers exist within the T&D standard but have declined to participate in the plan's network despite documented outreach efforts. The documentation requirements differ between these two situations, and CMS evaluates them differently. Plans that conflate the two or use generic exception language for both situations significantly increase their rejection risk.

The Two Types of Exceptions CMS Recognizes

CMS recognizes two pathways for access exception requests. The first is an access plan exception — applicable when the shortage is structural, meaning the geographic area has insufficient provider supply to meet the T&D standard regardless of which plan is trying to contract. This applies most commonly in rural and frontier counties for specialties like psychiatry, nephrology, and certain surgical sub-specialties. For access plan exceptions, the plan must demonstrate the structural shortage through objective third-party data, typically HRSA Health Professional Shortage Area (HPSA) designations, CMS's own provider shortage analysis, or state health workforce data.

The second pathway is a good faith effort exception — applicable when providers exist but have declined to contract. This exception requires a different and more operationally intensive documentation package: a log of outreach attempts to each available provider (with dates, contact method, and response), documentation that the outreach was meaningful and not perfunctory, and an alternative access arrangement that protects members in the interim. Good faith effort exceptions are more scrutinized because CMS expects plans to make genuine efforts — not just one phone call and a letter — before treating a provider as unwilling to contract.

Documentation Requirements: Access Plan Exceptions

For an access plan exception based on geographic shortage, the core documentation elements are:

• HPSA or shortage area designation: A current HRSA HPSA designation for the relevant provider type and county is the strongest supporting document. HPSA designations are searchable in the HRSA Data Warehouse and should be pulled as of the filing date.
• Provider supply data: CMS's own provider directory data, NPPES counts, or state licensure board counts showing the number of actively practicing providers in the specialty within the T&D radius. The plan should demonstrate that even if every available provider were in-network, the T&D standard could not be met.
• Market context: A brief narrative explaining the structural factors (rural geography, low population density, specialty training pipeline gaps) that produce the shortage. CMS reviewers are more likely to approve exceptions that demonstrate the plan understands the market rather than ones that simply cite a statistic without context.
• Alternative access arrangement: Required for all exception types. See the section below for what CMS accepts.

Plans should retain all supporting documentation — not just what is submitted in HPMS — because CMS may request additional information during its review process, and the documentation will also be needed if CMS audits the adequacy filing at a later date.

Documentation Requirements: Good Faith Effort Exceptions

Good faith effort exceptions require the most detailed documentation and are the most frequently rejected exception type. The outreach log is the centerpiece of the submission. It must include: each provider contacted (NPI, name, practice address); the date of each contact attempt; the method of contact (phone, letter, email, in-person); the outcome of each attempt (no response, declined, negotiating, non-responsive after X attempts); and the reason for declination if provided. CMS expects multiple contact attempts over a meaningful time period — a single attempt per provider will not satisfy the good faith standard in most circumstances.

Plans should also document rate offers and any counter-offers where applicable. CMS has taken the position that a plan that offers rates significantly below market and then claims providers are "unwilling to contract" has not made a good faith effort. If rate was a factor in provider declination, the plan's exception submission should address it — either by documenting that the rates offered were at or near market, or by explaining why the plan's rate structure differs from market and how it affects contracting in this specialty.

Alternative Access Arrangements CMS Accepts

Every access exception submission must include an alternative access arrangement that describes how the plan will ensure members can access care in the specialty despite the network gap. CMS accepts several forms of alternative access arrangement, and plans should select the most robust arrangement available given the clinical nature of the specialty:

• Letters of Agreement (LOAs) with out-of-network providers: An LOA is an agreement with a specific out-of-network provider to accept the plan's in-network cost-sharing for members who use their services. LOAs are the strongest alternative access arrangement and are most likely to satisfy CMS when combined with solid shortage documentation.
• Telehealth access: For specialties where telehealth is clinically appropriate and CMS allows it as an adequacy substitute (behavioral health, certain primary care sub-specialties), documented telehealth access via contracted telehealth providers can serve as an alternative arrangement. CMS's current rules on which specialties permit telehealth substitution should be confirmed in the applicable year's Call Letter.
• Transportation assistance: For geographic shortage situations, documented transportation assistance programs (medical transportation benefit, mileage reimbursement, or NEMT coordination) that connect members to the nearest in-network provider outside the T&D radius.
• Extended hours and multi-site arrangements: Documentation that an in-network provider outside the T&D standard operates satellite clinics or extended hours that reduce effective access burden.

The alternative access arrangement should be documented with specificity — the provider name and NPI of any LOA partner, the telehealth vendor and contract reference for telehealth arrangements, or the transportation benefit description and coverage parameters. Vague descriptions of "members can access OON services at in-network cost" without a specific arrangement underlying that commitment are a common rejection trigger.

How to Format the Exception Request in HPMS

HPMS's network adequacy module requires exceptions to be entered at the county-specialty combination level. Each county where the plan fails to meet T&D for a given HSD category requires a separate exception entry. The entry fields typically include: exception type (access plan vs. good faith effort), narrative description of the shortage or outreach effort, alternative access arrangement description, and attachment fields for supporting documentation. Plans should not rely solely on the narrative fields — CMS reviewers give more weight to submissions that include attached documentation (outreach logs, HPSA designations, LOA copies) than to narrative-only submissions.

The quality of the HPMS entry matters. Exception narratives should be specific to the county and specialty in question — not copied and pasted from a generic template that applies to every exception in the filing. CMS reviewers process large volumes of exception requests and quickly identify templated, non-specific language. A county-specific narrative that references the actual provider shortage data, actual providers contacted, and actual alternative access arrangement in place is materially more likely to be approved.

Common Rejection Reasons and How to Avoid Them

CMS rejects access exception requests for a predictable set of reasons. The most common are:

• Insufficient outreach documentation: The outreach log does not document enough attempts, enough time elapsed, or enough providers contacted. Plans should contact every provider within a reasonable geographic radius (typically 1.5x to 2x the T&D standard) and make at least three contact attempts per provider before treating them as unresponsive.
• No credible alternative access arrangement: The submission states that OON access will be provided at in-network cost but does not document a specific LOA or other arrangement that makes this possible. CMS requires specificity.
• Specialty mis-classification: The exception is filed for the wrong HSD category. Plans sometimes file under a parent specialty category when the gap exists at a sub-specialty level, or vice versa. Each exception must be filed for the specific HSD category that is deficient.
• Stale shortage documentation: HPSA designations or provider supply counts that are outdated. Shortage data should be pulled as close to the HPMS filing date as possible.
• Repeat exceptions without remediation evidence: For county-specialty combinations that have been excepted in prior years, CMS expects to see evidence of continued recruitment efforts. A filing that shows the same exception with no new outreach activity signals that the plan has stopped trying to fill the gap.

How Exceptions Affect Adequacy Scores and Limits on Exception Use

An approved access exception does not count as passing adequacy — it is an exception to the adequacy requirement. CMS tracks exception rates by plan and uses them as an indicator of network quality. Plans with high exception rates across multiple counties and specialties face greater regulatory scrutiny and may be subject to compliance action even if individual exceptions are approved. Exceptions should be treated as a last resort after genuine recruitment efforts, not as a routine filing strategy for difficult-to-contract specialties.

CMS has also signaled — through guidance and through its audit and oversight actions — that it will scrutinize situations where the same county-specialty combination has been excepted for multiple consecutive years. Plans in this situation should be prepared to demonstrate active, escalating recruitment efforts in each filing cycle. CMS has the authority to reject repeat exceptions where the plan cannot show meaningful progress toward filling the gap, and repeated rejection of exception requests for the same county-specialty combination can jeopardize the plan's adequacy certification for the affected service area.