Grace period for non-payment, ACA Marketplace-subsidized members
The Affordable Care Act requires that we share with providers the plan status of ACA Marketplace members who are receiving the "subsidy" (Advanced Premium Tax Credit, or APTC).
Identifying members in a non-payment grace period
Providers, both participating and non-participating with Priority Health, will be able to identify members in the grace period:
- Proactively through EDI 270/271 eligibility checks, which are available in as little as three seconds; these include the paid-through date.
- Retroactively on the Remittance Advice
Determining the grace period
The total "grace period" for non-payment of premiums is three months. The ACA requires plans to pay claims for the first month of the premium grace period.
Processing claims in the first month of non-payment
The first month of premium non-payment we will pay claims. The informational code V12 and description below on the Remittance Advice will notify you that the premium is not paid.
V12 (message, first month of grace period):
Alert: This enrollee is in the first month of the advance premium tax credit grace period
Processing claims in the second and third months
After the first month of non-payment of premium, we will process claims for $0 subject to automatic reprocessing if the premium is paid. You'll see an indication on the RA that the claim was pended due to nonpayment of premium as opposed to "not payable."
OPE (first line, second and third month of grace period):
The disposition of the claim is undetermined during the premium payment grace period, per Health Insurance Exchange requirement.
V13 (message, second and third month of grace period):
Alert: This claim will automatically be reprocessed if the enrollee pays their premiums.
Reminder: Contracted providers should continue to bill Priority Health until member liability or disposition is established.
- Status claims
- Claims Inquiry tool guide
- Edits Checker tool guide
- Claim deadlines
- Set up electronic payments
- BH provider billing
- Facility billing
- Advanced practice professional billing
- Professional billing
More billing topics:
- ACA non-payment grace period
- Balance billing
- Clinical edits
- Check reissue procedure
- COB: Coordination of benefits
- Correcting claims
- Correcting overpayments & underpayments
- Diagnosis coding
- Dual-eligible members
- Front-end rejections
- Gender-specific services
- Medicaid billing
- NDC numbers on drug claims
- Office-based procedures billing
- Risk adjustment
- Unlisted codes, drugs & supplies