ACA plan FAQs for providers

Member ID cards will 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) - 320004841700

Dependent 1 (Jane Smith) - 320004841701

Dependent 2 (Daniel Smith) - 320004841702

Yes. That’s because members have no out-of-network benefits with any plan, in any state, except for emergencies. Note: The following list includes examples of specialties that may be considered direct access and referrals may not be required:* 

• 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, you can use our online provider search.

Search Aetna CVS Health providers

Search Banner|Aetna providers

Search Innovation Health providers

 

*You can review our provider manuals and associated materials online to confirm your state’s direct access referral requirements.

**Note: Some services and equipment may require precertification. To confirm benefit information, 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 elected 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. Medicare payments are excluded from the total allowed charges. Aetna CVS Health considers the allowance based on the member’s responsibility after Medicare has considered the claim.

We’ll 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 plan & 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. So they are not considered out of network even if they are outside of the service area.

Simply select your location below to find formulary information.
 

Arizona (Banner|Aetna)
California
Delaware
Florida
Georgia
Illinois
Missouri
New Jersey
North Carolina
Nevada
Texas
Northern Virginia (Innovation Health)
Richmond and Roanoke, Virginia

Yes, the payer ID and claim address are the same for exchange plans. For information on electronic claims submission, see 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:
  Aetna
  PO Box 14079
  Lexington, KY 40512-4079
• Medical providers in Delaware, Illinois, Missouri, New Jersey, 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 that occur during the first month of non-payment. However, the grace period is different between 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, claims will be pended until premium payment is received in full. If the member doesn’t pay their premium and is terminated, claims paid for dates of service in months 2 and 3 will be denied.

For Texas members: Claims will be processed during the grace period. If the member doesn’t pay their premium and is terminated, claims paid for dates of service in months 2 and 3 of the grace period would be subject to overpayment recovery.

To determine if a member is in a grace period, log in to Availity to check benefits and eligibility. You will 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 requirements vary between 30 and 31 days. If the member doesn’t pay, their termination date will be effective retrospectively on the last day of the prior month that the premium was paid, and any paid claims with dates of service after termination would be subject to overpayment recovery.

For California members: California applies a 30-day grace period, and if the member doesn’t pay termination of coverage is prospective. Claims paid during the grace period are not subject to overpayment recovery.

We'll process the claim according to plan benefits. If the member has assigned benefits, Aetna CVS Health will pay you directly. Members have no out-of-network benefits on any plan, in any state, except for emergencies.

You’ll be reimbursed as outlined in your current contract (as applicable), or in a specific QHP rate schedule, if our network team has arranged one with you (usually for facilities only). For details, refer to your contract agreement/amendment.