Overview and background
Requirement for provider notification
Federal regulations (45 CFR 156.270) specify requirements that must be followed for terminating the coverage of Health Insurance Exchange enrollees who are receiving advance payments of premium tax credits (APTC). The requirements include:
- allowing APTC enrollees a three month grace period before terminating coverage due to nonpayment of premiums*;
- the Qualified Health Plan issuer (QHP - insurer) must pay all appropriate claims for services rendered to the enrollee during the first month of the grace period, regardless of whether the enrollee subsequently pays the premium for the first month of the grace period or not. The QHP may pend claims for services rendered to the enrollee in the second and third months of the grace period;
- the QHP must notify providers that may be affected by the enrollee’s premium payment grace period that an enrollee has lapsed in his or her payment of premiums. The notice may be exchanged via automated electronic processes, and must indicate there is a possibility that the issuer may deny payment of claims incurred during the second and third months of the grace period if the enrollee exhausts the grace period without paying the premiums in full.
Issuers are encouraged to notify all potentially affected providers as soon as is practicable when an enrollee enters the grace period, since the risk and burden are greatest on the provider.
*Note: In order for the APTC enrollees to be eligible for the three month grace period, the enrollees must also have previously paid at least one full month's premium during the benefit year.
Need for best practice
There is no current ASC X12 technical report specifically for the provider notification described above. The AUC developed and approved three best practices, using the transactions listed below, to be followed when satisfying the provider notification requirements above. The AUC’s best practices reflect and incorporate similar draft ASC X12 best practices.