Notice to PCP: member coverage suspended during delinquent premium grace period
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Governs notification to a primary care provider (PCP) that an enrollee's coverage is suspended during the second or third month of the Affordable Care Act three-month premium grace period and describes implications for authorizations, capitation, claims, and provider obligations.
No material clinical or coverage changes in this revision.
Coverage Suspension — Operational Effects
Coverage suspension consequences
Operational effects when an enrollee is in the second or third month of the ACA three-month premium grace period:
Provider options while coverage is suspended
- Participating providers are not contractually required to provide services to the enrollee while coverage is suspended.
- Providers may require payment from the enrollee when services are rendered during the suspension.
Provider Obligations and Authorization Handling
Cancel prior authorizations during months 2–3 of ACA grace period
Outstanding prior authorizations are cancelled when the enrollee is in the second or third month of the ACA three-month grace period; any outstanding authorizations for service provided by Health Net or a delegated entity are no longer valid while coverage is suspended. If you render services while coverage is suspended, claims will be pended and no capitation will be paid during the suspension; if the member pays all premiums before the end of the grace period, coverage (and applicable capitation and claims payment) is reinstated retroactively.
- Outstanding prior authorizations are not valid during months 2–3 of the grace period.
- Services rendered while coverage is suspended will result in pended claims and no capitation payment.
- If the enrollee pays all premiums before the end of the grace period, coverage and payment are reinstated retroactively.
Grace Period Definitions and Eligibility Status
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