The Advanced Premium Tax Credit (APTC) is part of the Patient Protection and Affordable Care Act, also known as Health Care Reform. The APTC helps qualifying individuals and families obtain health insurance by reducing monthly premiums.

As previously communicated, Health Care Reform mandates a three-month grace period for APTC members who are delinquent in paying their portion of the premiums. Please note that members must first pay their initial premium payment to be eligible for the grace period.

Under this mandate, insurers are required to pay medical claims received during the first 30 days of the grace period, but may pend medical claims for services rendered to those members and their eligible dependents during the second and third months of the grace period. Insurers are also required to notify affected providers when one of these members enters the grace period. If payment is not received by the end of the grace period, the pended claims will be denied and the member's policy will be terminated.

Delinquent payment indicator

To comply with the mandate, AmeriHealth has created a new field called APTC (Advanced Premium Tax Credit), which is available within the Eligibility and Benefits Inquiry transaction on the NaviNet^® web portal. This field indicates when a member is in the grace period and provides a status of the member's claims. The APTC field will only display when a member is in a delinquency status. When the member enters the grace period, the APTC field will be populated on the Eligibility and Benefits Details screen with the word "Yes." There will be a corresponding message that indicates the month of delinquency the member is in and the status of his or her claims.

If claims incurred in the second and third month are denied due to non-payment of premium by the end of the grace period, and the member's policy is terminated, providers may seek reimbursement directly from the member. However, if the premium is paid in full before the grace period ends, any pended claims will be processed in accordance with the terms of your Provider Agreement.

For more information

Please refer to the Delinquent Payment Indicator for APTC Members user guide for detailed information about the APTC field. This guide is available in the NaviNet Transaction Changes section of our System and Process Changes site.

If you have any questions about this mandate, please call Customer Service at 1-800-275-2583 for providers in Pennsylvania and Delaware and at 1-888-YOUR-AH1 (1-888-968-7241) for providers in New Jersey.

If you have questions regarding NaviNet transactions, please call the eBusiness Hotline at 215-640-7410 for providers in Pennsylvania and Delaware and at 609-662-2565 for providers in New Jersey.

NaviNet^® is a registered trademark of NaviNet, Inc.