Supporting our providers and their staff.
PROVIDER TIDBITS
TB00132013
A Guide for Understanding APTC Grace Periods
The Affordable Care Act (ACA) allows eligible customers to receive an advanced premium tax credit (APTC) for the purpose
of lowering the customer’s premium out-of-pocket costs. Only those whose income is 100 to 400 percent of the Federal
Poverty Level (FPL) are eligible for the APTC subsidy and only if they apply for it. Customers must apply for their subsidy
online through the healthcare “Marketplace” (also called “the exchange”). Open enrollment occurs for individuals, families
and small businesses each year between October 1 and March 31.
APTC can be used in advance to help lower the customer’s premiums. An aspect of receiving an APTC is the three-month
premium payment grace period. It acts as a coverage safety net for customers who have delinquent premium payments.
This is a standard ACA requirement, regardless of the customer’s healthcare carrier.
In this tidbit, we will expand upon how to find grace period information as it applies for customers who purchase Blue
Cross and Blue Shield of Louisiana policies.
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Contract # Search
Coverage Information
Coverage Summary
Eligibility
Contract Benefits
FEP Benefits and Eligibility
APTC Grace Period Explanation
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• ACTIVE PENDING PREMIUM PAYMENT - when the APTC
member is within the second and third months of the
delinquency period.
Claims Research
The Eligibility screen also includes the grace period begin and
end dates when the APTC member is in the grace period.
Claims Status
ITS Out of Area Claims
Action Request Inquiry
Check Information
Claims Tracking
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Medical Record Requests
Allowable Charges
Authorizations
Confirmation Reports
EFT Notifications
COVERAGE INFORMATION >Eligibility
Includes a printable APTC premium status notice when the APTC
member’s policy is in the premium grace period:
• ACTIVE COVERAGE - when the APTC member is NOT
delinquent OR within the first month of the delinquency
period.
Claims Entry
- Out Of Area
COVERAGE INFORMATION >Coverage Summary
An APTC premium status indicator will show on the Coverage
Report(s) on the Coverage Summary page.
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COVERAGE INFORMATION >APTC Grace Period Explanation
This is a link to a printable PDF copy of this Provider Tidbit
guide. It outlines where to locate premium status information on
iLinkBLUE for APTC members.
CLAIMS RESEARCH >Claims Status
Under the “Pended Claim Search Categories” there will be a new
pended claim search category for “APTC Extended Grace Period.”
CLAIMS RESEARCH >Claims Status >Pended Claims >Pended
Error Code Description
Click the “Pended Error Code” link and a Pended Error Code
Description box pops up. APTC members will show their premium
status under the Blue Cross reason code SL16.
The next few pages will walk you through each place within iLinkBLUE where APTC premium status information is available.
This publication is provided by the Network Administration Division of Blue Cross and Blue Shield of Louisiana. If you have a question regarding this communication,
please email [email protected] or call 1-800-922-8866. Please be sure to reference the Tidbit number listed at the top of this publication.
18NW2108 R02/16
Last reviewed on: 02-17-16
Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association
and incorporated as Louisiana Health Service & Indemnity Company.
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TB00132013
Supporting our providers and their staff.
PROVIDER TIDBITS
1
COVERAGE INFORMATION >Coverage Summary - On the Coverage Summary page, enter the member’s contract number
then press “Submit.” In the search results, click the “Coverage Report” button(s) on the Coverage Summary page to open the
Health Benefit Plan Coverage page where a premium status indicator can be found.
Coverage Summary
Contract #
Health Benefit Plan Coverage
Submit
Medical
Search Results
Contract # XUP123456789
Member Name
Date of Birth OED
Portability Date
Cancel Date
John Q. Subscriber
01/01/2000 01/01/2013
01/01/2000
Contract Type
Health
Coverage Report
Contract ID
XUP123456789
Subscriber Name
John Q. Subscriber
Member Name
John Q. Subscriber
Member DOB
01/01/2000
Relation to Sub
SELF
Sex
MALE
Health Eff Dt
01/01/2000
Health Port Dt
01/01/2000
Contract Status
ACTIVE PENDING PREMIUM PAYMENT
Contract Type
GROUPCARE PREFERRED CARE
Pre-Cert Reqmts
2nd Surg Opin
Direct Access
YES
One of the following contract statuses will show on the Health Benefit Plan Coverage page:
•
•
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ACTIVE COVERAGE - when the APTC member is NOT delinquent OR within the first month of the delinquency period.
ACTIVE PENDING PREMIUM PAYMENT - when the APTC member is within the second and third months of the
delinquency period.
COVERAGE INFORMATION >Eligibility - The contract status will show either “Active Coverage” or “Active Pending Premium
Payment.” When it shows the latter, it will link to an APTC premium status notice.
Eligibility Information
Please print
grace period
notice for
your records.
Contract #
Submit
Contract # XUP123456789 Contract Status Active Pending Premium Payment
Grace Period Begin Date: 08/01/2014
Grace Period End Date: 10/31/2014
Contract Information
When the contract status shows “Active Pending Premium Payment,”
there is a link to a printable PDF notice of the members premium
status. This status shows when the APTC member is in either the
second or third month of the grace period. The notice is generated
in real time based on the member’s current premium status. It is
important to print a copy of the notice for your records. The notice
is not stored in iLinkBLUE and is subject to change based on the
member’s policy premium status. This notice is not available if the
member’s status returns to “Active Coverage.”
The top of each report includes an APTC Extended
Period Notice number. It identifies the member
ID number, first day of the grace-period and the
provider’s 5-digit iLinkBLUE identifier.
APTC Extended Period Notice Number Example:
1234567890201201412345
This publication is provided by the Network Administration Division of Blue Cross and Blue Shield of Louisiana. If you have a question regarding this communication,
please email [email protected] or call 1-800-922-8866. Please be sure to reference the Tidbit number listed at the top of this publication.
18NW2108 R02/16
Last reviewed on: 02-17-16
Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association
and incorporated as Louisiana Health Service & Indemnity Company.
2
TB00132013
Supporting our providers and their staff.
PROVIDER TIDBITS
3
COVERAGE INFORMATION >APTC Grace Period Explanation - This is a new link that was added to the iLinkBLUE menu
bar. Clicking on this link opens a printable PDF of this Provider Tidbit guide. This guide is designed to help providers
understand the grace period and use iLinkBLUE to identify and manage their Blue patients in a grace period.
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CLAIMS RESEARCH >Claims Status - Today, providers have the option to search pended claims based on member policy
types (i.e. All, Federal, ITS BlueCard, Reg BC and Supplemental). Soon we will be adding another option to the Pended
Claim Search Categories for claims pended specifically for the “APTC Extended Grace Period.”
Claims Status
Select a Provider
Claim Type Paid/Rejected
Pended Claim Search Categories
PendedAll
Optional for Pended Claim Type:Federal
Reg BC
Contract #ITS BlueCard
Supplemental

APTC
Extended Grace Period
Optional for All Claim Types:
Beginning DOS:
Ending DOS:
1
Submit
Reset
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Select the “APTC Extended Grace Period” category then press the Submit button. This will bring you to the Pended Claims
screen. Click on the “Pended Error Codes” link to view the Pended Error Code Description information in a separate pop-up
window.
Pended Claims
Contract ID: XUP123456789
New Search
Search returned 2 records.
Viewing records 1 through 2.
Printable View
Page 1of 1
Contract ID: XUP123456789
Patient Account Number
Date of
Service
Patient
Name
Amount
Charged
CPT4
CD
Codes
Pended
Error
Codes
Claim
Number
Details
AR
ABC123ABC123
01/01/2013
John Q Subscriber
$30.00
96372
55
321321321-2
AR
ABC123ABC123
01/01/2013
John Q Subscriber
$305.00
9920425
55
321321321-1
This publication is provided by the Network Administration Division of Blue Cross and Blue Shield of Louisiana. If you have a question regarding this communication,
please email [email protected] or call 1-800-922-8866. Please be sure to reference the Tidbit number listed at the top of this publication.
18NW2108 R02/16
Last reviewed on: 02-17-16
Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association
and incorporated as Louisiana Health Service & Indemnity Company.
3
Supporting our providers and their staff.
PROVIDER TIDBITS
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TB00132013
CLAIMS RESEARCH >Claims Status >Pended Claims >Pended Error Code Description - When the HIPAA pended code
“55” link is clicked, you will see the following pop-up window:
Pended Error Code Description
Type
Code
Description
HIPAA
55
CLAIM ASSIGNED TO AN APPROVER/ANALYST.
HIPAA Category
P2
PENDING/IN REVIEW-THE CLAIM/ENCOUNTER IS SUSPENDED PENDING
BCBSLA
SL16
CLAIM PENDING PREMIUM DUE TO APTC MEMBER EXTENDED GRACE PERIOD
The HIPAA pended codes and messages are standard for both APTC and non-APTC members with pended claims. However, the
Blue Cross reason code SL16 message will vary for APTC and non-APTC members. When the Blue Cross pended code is related
to the APTC grace period, it will be a link that also generates a real-time APTC grace period notice (same as the link found on
the Eligibility page of iLinkBLUE).
Note: Blue Cross reason code SL16 message will state “Pending an update from the group/member,” when the pended status is
NOT related to the APTC grace period and will not be a link the APTC grace period notice.
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What to do when a policy is terminated - When an APTC member’s policy is terminated for non-payment at the end of
the three-month grace period, the policyholder’s healthcare insurer then denies the pended claims for eligibility for dates
of service during the second and third months of the member’s premium grace period. As required by the ACA law, claims
paid for dates of service that occur during the first month of the grace period cannot be denied for eligibility due to the
policyholder’s premium delinquency. Once claims are denied for services rendered during the second and third months of the
grace period, the provider may then seek reimbursement directly from the member up to the billed charges amount(s). If you
have already collected the allowed amount(s) from the member, you may then collect the amounts still owed to you up to your
billed charges.
This publication is provided by the Network Administration Division of Blue Cross and Blue Shield of Louisiana. If you have a question regarding this communication,
please email [email protected] or call 1-800-922-8866. Please be sure to reference the Tidbit number listed at the top of this publication.
18NW2108 R02/16
Last reviewed on: 02-17-16
Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association
and incorporated as Louisiana Health Service & Indemnity Company.
4
Supporting our providers and their staff.
PROVIDER TIDBITS
TB00132013
7
Grace period information included on electronic transactions (27x) - To inquire about eligibility and benefits
electronically, providers can submit a 270 Eligibility Benefit Inquiry. To obtain a claim status, providers can submit a 276
Claim Status Request.
When Blue Cross receives a 270 Inquiry for an APTC member with a policy that is pending for premium payment, the provider
will receive a 271 Response that has been enhanced to include the premium paid to date end, grace period start date, grace
period end date and grace period informational message.
The 271 Response also now includes Blue Cross’ HPID (unique health plan identification number). Also included with the HPID
is the product name. Blue Cross has two HPIDs as follows:
HPID 7598768720 - for HMO Louisiana, Inc. policies
HPID 7780687910 - for Blue Cross and Blue Shield of Louisiana policies
premium paid to date end - (found on loop 2100C/D DTP) - This is the last day of coverage for which a premium
payment has been received and applied. This is the last day of active coverage or the day before the beginning of the
grace period. It is displayed in the 271 Response as code 343.
grace period start date - (found on loop 2110C/D DTP) - This is the first day of the grace period. It is displayed in the
271 Response as code 193.
grace period end date - (found on loop 2110C/D DTP) - This is the last day of the grace period. It is displayed in the
271 Response as code 194.
grace period informational message - (found on loop 2110C/D DTP below the grace period start and end dates) - This
is an informational field on the 271 response that indicates the subject of the data in fields above. It is displayed in the
271 Response as HIX GRACE PERIOD (HIX - health insurance exchange).
Below is a sample section of the 271 Response that includes the codes defined above:
DTP*291*RD8*20150101-20151231~
DTP*382*D8*20150101~
DTP*539*D8*20150101~
DTP*343*D8*20150731~
- premium paid to date end (shows last day of active coverage as July 31, 2015)
EB*1*EMP*30*PR*Individual Blue Max 7780687910~
- HPID (shows a PPO product and Blue Cross HPID)
DTP*193*D8*20150801~
- grace period start date (shows first day of grace period as August 1, 2015)
DTP*194*D8*20151031~
- grace period end date (shows last day of grace period as October 31, 2015)
MSG*HIX GRACE PERIOD~
- grace period informational message
When Blue Cross receives a 276 Claim Status Request for an APTC member with a policy that is pending for premium payment,
the provider will receive a 277 Claim Status Response that has been enhanced to include claim status code 766 (found on loop
2220D/E STC). This means the claim is pending because services were performed during a Health Insurance Exchange
(HIX) premium payment grace period.
Below is an example of what a 277 Claims Status Response will look like:
STC*P5:766*20151103~
- services were performed during a Health Insurance Exchange (HIX)
premium payment grace period
This publication is provided by the Network Administration Division of Blue Cross and Blue Shield of Louisiana. If you have a question regarding this communication,
please email [email protected] or call 1-800-922-8866. Please be sure to reference the Tidbit number listed at the top of this publication.
18NW2108 R02/16
Last reviewed on: 02-17-16
Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association
and incorporated as Louisiana Health Service & Indemnity Company.
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