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As previously communicated, the Patient Protection and Affordable Care Act,
also known as Health Care Reform, mandates a three-month grace period for
individual members who receive a premium subsidy from the government and are
delinquent in paying their portion of the premiums.
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.
To comply with the mandate, IBC will notify affected providers by mail upon
receipt of a claim for services rendered for a member who is within the second
or third month of the grace period. In addition, a new field called APTC
(Advanced Premium Tax Credit) is available within the Eligibility and Benefits
Inquiry transaction on the NaviNet® web portal to show providers
when a member is in the grace period and provide 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 (as shown below) 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 payment
is not received before the grace period expires, the member?s policy will be
terminated.
If you have any questions about this mandate, please call Customer Service at
1-800-ASK-BLUE (1-800-275-2583). 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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