ACA PATIENTS AND YOUR PRACTICE—
A FOUR-PART SERIES
Part Two:
Verifying Eligibility for Every Patient
Jennifer Searfoss, J.D., C.M.P.E.
Early in the year, validating coverage eligibility for every insured patient is an essential part of your
revenue cycle management. Patients are most likely to change insurance carriers at the beginning of
the year, their deductibles reset and they may have new copay amounts.
The best solution is to be proactive and validate
patient eligibility at every appointment. An eligibility
transaction can be automatically set in many practice
management systems or run through a clearinghouse
web portal or health plan provider website.
To run an eligibility check, you will need:
• Patient’s full name (as it appears on the insurance
card)
• Patient’s date of birth
• Member number and group number (if applicable)
A best practice is to run eligibility three to five days
before their visit, so that you can let the patient know
about any high out-of-pocket costs that could be
incurred during their appointment reminder call. You
can also use the reminder call to explain your payment
policy for reimbursement at the time of service and
any issues with their premium payment status.
Eligibility should be run again the morning of the
appointment to ensure that there were no changes to
their insurance status prior to rendering service.
Eligibility and the 90-day Grace
Period
What to Look for
in an Eligibility Response
Active coverage: Is the patient currently
covered and active (for the patient and
any dependents)?
Coinsurance: What is the patient’s outof-pocket liability including deductible and
copayment for services in your specialty
(primary care, specialist, therapy, urgent
care, etc.)?
Deductible met: What is the current
amount owed to meet the deductible for
the individual or family coverage? The
full amount must be paid by the patient
before insurance kicks in, except for
certain preventive services.
APTC indicator: Is there an APTC
indicator? For patients with insurance
bought on a state or federal exchange
that received the federal tax incentive,
check that they paid up on premiums. An
indicator will show that they are not paid
in full and coverage may be in jeopardy.
Anyone covered under a commercial plan that is
bought on a health exchange and subsidized by a
federal Advanced Premium Tax Credit (APTC) is
entitled to a 90-day grace period. During this period the health plan holder can fall behind on his
or her premiums and still retain access to health coverage. Commercial insurance products bought
outside the exchange, as well as the 15 percent of ACA exchange plan buyers who don’t receive a
Jennifer Searfoss is the CEO
of the Searfoss Consulting
Group, LLC and is focused
on revenue cycle management and strategic planning.
Prior to starting Searfoss
Consulting Group, Jennifer
was the Vice President of
External Provider Relations
for United Healthcare where
she established and led the
Provider Communications
& Advocacy unit. Jennifer
has also had the pleasure of
teaching at the University of
Maryland, Baltimore County.
She serves on the board
of the Maryland Medical
Group Management Association and is a clinical advisor
for Informatics.
federal tax subsidy, are not entitled to any type of grace period. Also, the grace period does not
apply to patients covered by Medicare or Medicaid plans.
For the first 30 days of non-payment of the insurance premium, the health plan is supposed to
continue to process and pay claims for dates of service during that period as though the coverage
was still in force and paid up-to-date. After that, the claim will pend until the patient gets caught
up on all premiums. Claims will ultimately be denied for non-coverage if the patient doesn’t pay all
the owed premiums.
The timing of the 90-day policy is based on the date of
service. And the grace period is counted in calendar days
and not business days. The period starts from the date of
non-premium payment (often January 1 or the first day of
a month).
The 90-day grace period applies equally to in-network
providers and non-participating providers that seek
payment from a health plan for out-of-network coverage.
Note that the 90-day grace period only applies to
services. Claims for prescriptions, durable medical
equipment, orthotics or supplies will be denied as soon as
a premium payment falls behind.
First 30 Days
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Days 31-60
X
X
X
X
X
X
X
X
Plan pays for claims
with dates of service in
the first 30 days of
premium payment.
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Days 61-90
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Claims are pended until premiums are brought
current; ultimately denied without payment.
But not all states allow the 90-day grace period. Learn more about the grace period
in a comprehensive white paper by Jennifer Searfoss. Click here for your copy.
Finding APTC Patients—Selected Payer Responses
Aetna: Aetna member ID cards will include a “QHP” designation for all exchange beneficiaries. The plan states that eligibility will
confirm if a patient is behind on premium payment but that it cannot confirm the length of the grace period; just that the claims are
pended. Read more on the Aetna web site.
Independence Blue Cross: A new indicator on web portal electronic eligibility requests will display only when an APTC beneficiary
is in delinquency status for his/her premium. The indicator will say “yes” and specify the month of delinquency and the status of
claims payment.
UnitedHealthcare: Patient eligibility conducted on UnitedHealthcareOnline.com or the new Optum Cloud Dashboard features a
new section entitled “Exchange participant claim eligible through” and it specifies when the 30 day period following premium nonpayment began. The payer will also include information about premium payment for exchange participants during prior authorization
requests and telephone eligibility inquiries. Read more in their frequently asked question document.
For more information on how TriZetto Provider Solutions helps you
keep more of your focus on patients, not payment, call
800-969-3666, visit us online, or send us e-mail
TriZetto Provider Solutions
501 N. Broadway
3rd Floor
St. Louis, MO 63102
1-800-969-3666
www.trizetto.com
Copyright © 2015 TriZetto Corporation. All rights reserved. TriZetto and the TriZetto Triangle logo are registered trademarks and TriZetto Provider Solutions is
a Trademark of TriZetto Corporation or its sub­sidiaries. Other company and product names may be trademarks of the respective companies with which they are
associated. The mention of such companies and product names is with due recognition and without intent to misappropriate such names or marks.
0215