ACA plan FAQs for providers

Member ID cards have "QHP" on them. The product name and the plan name are on the right side of the card. There is also a dedicated toll-free number for Member Services.

Regardless of where the member purchased the plan, you will verify benefits and eligibility as you normally do. With our Availity^® provider portal, it’s easy to manage many tasks online. You can submit claims, check claim status and patient eligibility, request precertification, submit disputes and appeals, and more.

Log in to Availity

Don’t have an Availity account ?

• If your practice already uses Availity: Contact your Availity administrator to request a username. If you don’t know who your administrator is, call Availity Client Services at 1-800-282-4528 for help.
• If your practice is new to Availity: Find registration instructions to set up your Availity account.

Use the number ending in “00” for the subscriber’s member ID number. Submitting requests (such as a claim or prior authorization request) for someone other than the subscriber? Replace the “00” with the last two numbers that apply to that person.

Here’s an example: 

Subscriber (Joseph Smith) - 10XXXXXXXX00

Dependent 1 (Jane Smith) - 10XXXXXXXX01

Dependent 2 (Daniel Smith) - 10XXXXXXXX02

Yes. That’s because members do not have out-of-network benefits with any plan, in any state, except for emergencies. 

These specialties allow direct access, and may not require referrals:*

• Behavioral health
• Durable medical equipment*
• Gynecology care (obstetrician/gynecologist)
• Home health care
• Hospital ambulatory surgery*
• Hospital outpatient*
• Mid-level practitioners (for example, physician assistants, nurse practitioners)
• Oral surgery
• Preventive care
• Radiology, pathology and lab*
• Therapy (physical therapy, occupational therapy, speech therapy)

To find providers in the exchange network, use our online provider search.

Search Aetna CVS Health providers

Search Banner|Aetna providers

Search Innovation Health providers

 

Notes

*FOR DIRECT ACCESS TO SPECIALISTS: Reference our Provider Manual and related materials online to confirm your state’s direct access referral requirements.

*FOR DURABLE MEDICAL EQUIPMENT, HOSPITAL AMBULATORY SURGERY, HOSPITAL OUTPATIENT AND RADIOLOGY, PATHOLOGY AND LAB: Some services and equipment may require precertification. To confirm benefits, call your provider support team at 1-888-632-3862 (TTY: 711).

ACA individual insurance plans only coordinate with Medicare coverage. If the member is eligible for Medicare and elects Medicare coverage, then Medicare will always be primary.

Individual insurance plans use Government Exclusion (GE) to coordinate with Medicare. GE is a method of determining Aetna payment when Medicare is the primary insurance for the member. We exclude Medicare payments from the total allowed charges. Aetna CVS Health® considers the allowance based on the member’s responsibility after Medicare has considered the claim.

We automatically assign most members a PCP except for those in Missouri, New Jersey, North Carolina, and Virginia (Aetna CVS Health members in Roanoke and Richmond). Members can also call us to choose their PCP. Then we’ll mail them a new ID card.

There are no out-of-network benefits with any Aetna CVS Health individual & family plan, in any state, except for emergencies. If Aetna CVS Health approves something, it would be at the in-network benefit and at a contracted rate (if broad network provider) or LOA negotiated.

Note: MinuteClinic^® locations and some labs have a national network. We do not consider them out of network even if they are outside of the service area.

To find state formulary information and other drug coverage resources, select a state:
 

Arizona (Banner|Aetna)
California
Delaware
Florida
Georgia
Illinois
Indiana
Kansas
Maryland
Missouri
Nevada
New Jersey
North Carolina
Ohio
Texas
Utah
Virginia – Northern (Innovation Health)
Virginia – Southern

Yes, the payer ID and claim address are the same for exchange plans. For information on electronic claims submission, review our claims, payment & reimbursement resources.

We encourage electronic claims submission. However, if you prefer to mail a claim, you can use the address below:

• Medical providers in Arizona, California, Florida, Georgia, North Carolina, Nevada, Utah:
  Aetna
  PO Box 14079
  Lexington, KY 40512-4079
• Medical providers in Delaware, Illinois, Indiana, Kansas, Maryland, Missouri, New Jersey, Ohio, Texas, Virginia:
  Aetna
  PO Box 981106
  El Paso, TX 79998-1106

No, the existing claims filing limits will apply. Check out insurance regulations by state for more information on timely filing standards.

That means we’ll continue to pay any claims from the first month of non-payment. However, the grace period is different between for members who receive premium subsidies (Advance Premium Tax Credit) and those who don’t:  

For on-exchange members who receive premium subsidies: There is a 90-day premium payment grace period. In all states except Texas, at the start of the second month of non-payment, we hold claims until we receive the full premium payment.  If the member doesn’t pay their premium and we terminate coverage, claims for services in months two and three of the grace period are denied.

For Texas members: Claims are processed during the 90-day grace period. If the member doesn’t pay their premium and we terminate coverage, claims for services in months two and three of the grace period are subject to overpayment recovery.

To determine if a member is in a grace period, log in to Availity to check benefits and eligibility. You'll see “HIX Grace Period” under Plan/Product if the member is in a grace period.

For on-exchange members who don’t receive premium subsidies or off-exchange members: The grace period varies between 30 and 31 days. If the member doesn’t pay, their coverage termination date is the last day of the prior month that they did pay. Any paid claims with dates of service after coverage is terminated are subject to overpayment recovery.

For California members: California has a 30-day grace period. If the member doesn’t pay, termination of coverage is likely. Claims we pay during the grace period aren't subject to overpayment recovery.

We process the out-of-network claims according to plan benefits. If the member has assigned benefits, Aetna CVS Health will pay you directly. Members don’t have out-of-network benefits with any plan, in any state, except for emergencies.

You’ll be reimbursed as:
 

• Outlined in your current contract (as applicable), or
•  Indicated in your specific QHP rate schedule, if our network team has arranged one with you (usually for facilities only)

For details, refer to your contract agreement or amendment.