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 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.
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