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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, IBC 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 Business
Transformation site.
If you have any questions about this mandate, please call Customer Service
at 1-800-ASK-BLUE. If you have questions regarding NaviNet transactions,
please call the eBusiness Hotline at 215-640-7410.
NaviNet® is a registered trademark of
NaviNet, Inc., an independent company.
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