Grace period for non-payment, ACA Marketplace-subsidized members

The Affordable Care Act requires that we share with providers the plan status of ACA Marketplace members who are receiving the "subsidy" (Advanced Premium Tax Credit, or APTC).

Identifying members in a non-payment grace period

Providers, both participating and non-participating with Priority Health, will be able to identify members in the grace period:

  • Proactively through EDI 270/271 eligibility checks, which are available in as little as three seconds; these include the paid-through date. 

    Learn more about electronic data interchange (EDI).

  • Retroactively on the Remittance Advice

Determining the grace period

The total "grace period" for non-payment of premiums is three months. The ACA requires plans to pay claims for the first month of the premium grace period.

Processing claims in the first month of non-payment

The first month of premium non-payment we will pay claims. The informational code V12 and description below on the Remittance Advice will notify you that the premium is not paid. 

V12 (message, first month of grace period):

Alert: This enrollee is in the first month of the advance premium tax credit grace period  

Processing claims in the second and third months

After the first month of non-payment of premium, we will process claims for $0 subject to automatic reprocessing if the premium is paid. You'll see an indication on the RA that the claim was pended due to nonpayment of premium as opposed to "not payable."

OPE (first line, second and third month of grace period):

The disposition of the claim is undetermined during the premium payment grace period, per Health Insurance Exchange requirement.

V13 (message, second and third month of grace period):

Alert: This claim will automatically be reprocessed if the enrollee pays their premiums.

Reminder: Contracted providers should continue to bill Priority Health until member liability or disposition is established.


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