I am requesting a network gap exception. My plan's access standard for [specialty] is [X miles / X business days]. Between [dates] I contacted [number] in-network providers listed in your directory, and none could see me within that standard; the calls are listed on the attached page with dates, numbers and responses. I have identified [name, credentials, address], who is willing to treat me and bill the plan. Please authorize out-of-network care with [name] at in-network cost sharing, in writing, by [date]. I am copying [the state insurance department / the Department of Labor].
