Notice to Provider: Patient Coverage Suspended During ACA Premium Grace Period
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Explains Health Net National's process for notifying providers when a member's coverage is suspended during the second and third months of a three-month premium grace period and the implications for claim payment and prior authorizations; applies to providers who rendered services to affected enrollees.
No material clinical or coverage changes in this revision.
Coverage and Claim Handling During ACA Premium Grace Period
Grace period coverage rules
Coverage and claim handling based on grace period month:
ALL of the following
- Coverage remains in effect; claims for covered services are eligible for payment
ALL of the following
- Claims for services rendered during this period are pended
- Any outstanding authorizations for services provided by Health Net or a delegated entity are no longer valid
ANY of the following
- Coverage is reinstated
- Claims for covered services become eligible for payment
ALL of the following
- Coverage is terminated as of the end of the first month of the grace period
- No claims will be paid for services rendered after that date
Coding and Claim Status
Provider Responsibilities and Options When Coverage Is Suspended
Outstanding prior authorizations become invalid during suspended coverage
Any outstanding authorizations for services provided by Health Net or a delegated entity are no longer valid during the enrollee's suspended coverage (months 2 and 3 of the grace period).
Provider may require patient payment during suspended coverage
Health Net participating providers are not contractually required to provide services while the enrollee's coverage is suspended and may require payment from the patient at the time services are rendered.
- Providers may collect patient payment at point of service when coverage is suspended (months 2–3 of the ACA grace period).
- If the member subsequently pays all premiums due before the end of the grace period and coverage is reinstated, previously pended claims may become eligible for payment per policy.
Key Definitions
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