APTC Grace Period and Premium Payment Details Now Easier to Find
Delays in a HumanaOne® member’s premium payments may result in a pended or denied claim or a request for a claims refund. Humana offers several ways for health care providers to check a patient’s eligibility.
Using the Availity Web Portal, Humana.com secure portal, interactive voice response (IVR) or X12 transaction, health care providers will get a message or messages that will indicate if the following situations apply:
- The member’s initial premium payment has not been received.
- The member’s most recent premium payment has not been received.
- The member is within the first, second or third month of the advance premium tax credit (APTC) grace period. (The grace period month will be specified and a paid-through date provided.)
This information is provided whether the member is on-exchange or off-exchange. The grace period information applies only to on-exchange members receiving the APTC.
Grace period guidelines
If a member has a Marketplace plan and an advanced premium tax credit, the grace period is extended and claims are handled differently than for all other members. Following are the guidelines:
- Less than 30 days into the grace period: claims process as normal.
- Between 31-90 days into the grace period: claims pend and a letter is sent to the health care provider to advise of status.
- Greater than 91 days into the grace period: claims deny and the member’s coverage is terminated. The member will need to go back to the marketplace for a new policy.
If the claim is denied because of the member’s coverage termination, the member’s health care provider has the option to collect payment from the patient for the claim.
How to locate grace period and premium payment information
- Via the multipayer Availity Web Portal or Humana.com secure provider portal - Health care providers can sign in and complete a member eligibility check.
- Via interactive voice response (IVR) - Health care providers can call 1-800-448-6262, Monday through Friday, 8 a.m. to 8 p.m. Eastern time, and follow the prompts.
- Via X12 transaction - For electronic data interchange (EDI) transactions, health care providers can check the message (MSG) segment of the HIPAA X12 271 response.
Below is an example of a grace period message displayed on the Availity Web Portal:
Below is an example of a grace period message displayed on the secure Humana.com provider portal:
Health care providers who have Humana-covered patients with questions about their Marketplace health care coverage can direct them to Healthcare.gov or Humana.com.