For each of the multiple status Health Insurance Exchange Grace Period Notifications specified in 45 CFR 156.270(d)(2), Notifications to HHS, and 45 CFR 156.270(d)(3), Notifications to Providers, and in accordance with the provisions of Chapter 5, Section 7.ii, Notice of Pending Claims— to Providers, of the CMS Letter to Issuers for 2014 located at http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2… , which ASC X12 Transactions and/or Type 3 Technical Reports may optionally or should per-mandate be used? For each variant of each such status notifications transactions, which ASC X12 transaction loop-ID and data elements and code values [for data types ID as applicable] should be used to convey the specified data?
Related Regulatory References
TITLE 45 -- PUBLIC WELFARE
SUBTITLE A -- DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER B -- REQUIREMENTS RELATING TO HEALTH CARE ACCESS
PART 156--HEALTH INSURANCE ISSUER STANDARDS UNDER THE AFFORDABLE CARE ACT, INCLUDING STANDARDS RELATED TO EXCHANGES
SUBPART C--QUALIFIED HEALTH PLAN MINIMUM CERTIFICATION STANDARDS
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45 CFR 156.270
§ 156.270 Termination of coverage for qualified individuals.
(a) General requirement. A QHP issuer may only terminate coverage as permitted by the Exchange in accordance with § 155.430(b) of this subchapter.
(b) Termination of coverage notice requirement. If a QHP issuer terminates an enrollee's coverage in accordance with § 155.430(b)(2)(i), (ii), or (iii), the QHP issuer must, promptly and without undue delay:
(1) Provide the enrollee with a notice of termination of coverage that includes the termination effective date and reason for termination.
(2) [Reserved]
(c) Termination of coverage due to non-payment of premium. A QHP issuer must establish a standard policy for the termination of coverage of enrollees due to non-payment of premium as permitted by the Exchange in § 155.430(b)(2)(ii) of this subchapter. This policy for the termination of coverage:
(1) Must include the grace period for enrollees receiving advance payments of the premium tax credits as described in paragraph (d) of this section; and
(2) Must be applied uniformly to enrollees in similar circumstances.
(d) Grace period for recipients of advance payments of the premium tax credit. A QHP issuer must provide a grace period of three consecutive months if an enrollee receiving advance payments of the premium tax credit has previously paid at least one full month's premium during the benefit year. During the grace period, the QHP issuer must:
(1) Pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period;
(2) Notify HHS of such non-payment; and,
(3) Notify providers of the possibility for denied claims when an enrollee is in the second and third months of the grace period.
(e) Advance payments of the premium tax credit. For the 3-month grace period described in paragraph (d) of this section, a QHP issuer must:
(1) Continue to collect advance payments of the premium tax credit on behalf of the enrollee from the Department of the Treasury.
(2) Return advance payments of the premium tax credit paid on the behalf of such enrollee for the second and third months of the grace period if the enrollee exhausts the grace period as described in paragraph (g) of this section.
(f) Notice of non-payment of premiums. If an enrollee is delinquent on premium payment, the QHP issuer must provide the enrollee with notice of such payment delinquency.
(g) Exhaustion of grace period. If an enrollee receiving advance payments of the premium tax credit exhausts the 3-month grace period in paragraph (d) of this section without paying all outstanding premiums, the QHP issuer must terminate the enrollee's coverage on the effective date described in § 155.430(d)(4) of this subchapter, provided that the QHP issuer meets the notice requirement specified in paragraph (b) of this section.
(h) Records of termination of coverage. QHP issuers must maintain records in accordance with Exchange standards established in accordance with § 155.430(c) of this subchapter.
(i) Effective date of termination of coverage. QHP issuers must abide by the termination of coverage effective dates described in § 155.430(d) of this subchapter.
HISTORY:
[77 FR 18310, 18469, Mar. 27, 2012; 78 FR 42160, 42322, July 15, 2013; 78 FR 54069, 54143, Aug. 30, 2013]
AUTHORITY:
AUTHORITY NOTE APPLICABLE TO ENTIRE PART:
Title I of the Affordable Care Act, Sections 1301-1304, 1311-1312, 1321, 1322, 1324, 1334, 1341-1343, and 1401-1402, 1501, Pub. L. 111-148, 124 Stat. 119 (42 U.S.C. 18042).
NOTES:
[EFFECTIVE DATE NOTE: 77 FR 18310, 18469, Mar. 27, 2012, added Subpart C, effective May 29, 2012; 78 FR 42160, 42322, July 15, 2013, revised paragraph (b), effective Sept. 13, 2013; 78 FR 54069, 54143, Aug. 30, 2013, revised paragraph (b) introductory text, effective Sept. 30, 2013.]
_____________________
Date: April 5, 2013
From: Center for Consumer Information and Insurance Oversight, Centers for Medicare & Medicaid Services
Title: Affordable Exchanges Guidance
Subject: Letter to Issuers on Federally-facilitated and State Partnership Exchange
Chapter 5, Section 7.ii. Notice of Pending Claims—to Providers
In accordance with 45 C.F.R. § 1 56.270(d)(3), issuers must notify providers that may be affected (meaning at least providers that submit claims for services rendered during the grace period) that an enrollee has lapsed in his or her payment of premiums. Issuers may utilize automated electronic processes to convey such notices. The notice must indicate there is a possibility that the issuer may deny payment of claims incurred during the second and third months of the grace period if the enrollee exhausts the grace period without paying the premiums in full. Issuers should notify all potentially affected providers as soon as is practicable when an enrollee enters the grace period, since the risk and burden are greatest on the provider. Issuers should include the following information in the provider notification:
• Purpose of the notice;
• A notice-unique identification number;
• The name of the QHP and affiliated issuer;
• Names of all individuals affected under the policy and possibly under the care of this provider;
• An explanation of the three month grace period, including applicable dates, including: o Whether the enrollee is in the second or third month of the grace period,
o Consequences of grace period exhaustion for the enrollee and provider, and
o Options for the provider; and
• The QHP customer service telephone number specifically for use by providers, if available.
Multiple ASC X12 transaction technical reports may apply to the requirements identified in the referenced regulations and guidance, depending upon the specific timing and circumstances. None of the transaction implementations were written after the establishment of the related requirements, so none of the guides existing as of the date of the requirements identified in the referenced regulations and guidance provides explicit direction for these situations. Specifically:
- There is no current ASC X12 technical report identifying notification to the Department of Health and Human Services.
- There is no current ASC X12 technical report identifying notification to the provider as a notification report.
However, multiple transactions can provide some or all of the related information at various stages of the business process, as identified in the Recommendation below.
Recommendation:
The following solutions represent the best practices as identified by ASC X12N as of the date of this RFI, but do not establish any requirement that any specific entity implement these practices.
Note - Many of the codes referenced in the solutions below are owned by organizations external to ASC X12 and are not listed in the related ASC X12 Technical Reports. The Health Care Claim Status Codes (277 STC01-02), Health Care Claim Status Category Codes (277 STC01-01), Remittance Advice Remark Codes (835 MIA05, 20, 21, 22, 23, MOA03, 04, 05, 06, 07 or LQ02), and Claim Adjustment Reason Codes (835 CAS02, 05, 08, 11, 14 , 17) referenced in this document were obtained from www.wpc-edi.com, and are distributed by Washington Publishing Company (WPC). Since the descriptions of these code values is subject to change by the owning organizations, the WPC web site should be routinely accessed to obtain the current up-to-date descriptions.
Health Care Eligibility Benefit Information Request and Response:
Guide 005010X279 (Health Care Eligibility Benefit Information Request and Response (270/271) provides the most information required by the references. Usage for this purpose is described in RFI # 1806. In addition to that information, some of the requirements not addressed by RFI # 1806 can be met as follows:
- Unique Identification Number – 2000C or 2000D (as applicable) TRN segment, TRN02.
- Name of Qualified Health Plan or Issuer (QHP) – 2100A loop NM1 segment, NM103.
- Telephone number of the QHP customer service – 2100A PER segment where the related Communications Number Qualifier equals “TE”, meaning Telephone.
- Name of the individual – 2100C or 2100D (as applicable) NM1 segment, NM103, NM104 NM105.
- Explanation of the Grace Period, consequences for the enrollee and provider and purpose of the notice – should be pointed to by using the 2100A loop PER segment with a Communications Qualifier of “UR”, meaning Universal Resource Locator (URL), and the related URL as the Communication Number.
Health Care Claim Status Request and Response Information
When a health plan has received a claim with service dates within an active grace period, claim status information related to that claim should identify the existence of the grace period as long as the grace period is still in effect.
TR3 005010X214 (277CA) - Claim Acknowledgment
When:
- a health plan responds to a submitted electronic claim with a Health Care Claim Acknowledgment (277CA), and
- the response provides individual claim information, and
- a health plan responds to a submitted electronic claim with a Health Care Claim Acknowledgment (277CA), and
- the health plan can identify has the capability to perform enrollment processing in order to identify that the patient is in the grace period during editing of the received claim, and
- the response provides individual claim information, and
- an accepted for adjudication claim has one or more of the service dates within an active grace period
The health plan must return a 2200D loop STC segment with the following:
- STC01-01 equals “A2” (meaning “Acknowledgement/Acceptance into adjudication system-The claim/encounter has been accepted into the adjudication system.”)
- STC01-02 equals “766” (Meaning “Services performed during a Health Insurance Exchange (HIX) premium payment grace period.”)
- STC02 equals (the effective date of the status)
- STC03 equals “WQ” (meaning “Accept”)
- STC04 equals (Total Claim Charge Amount)
Pending claims
When the health plan receives a claim status request for a claim where:
- One or more of the service dates is within the grace period, and
- the claim is being pended and has not completed adjudication (either because of the grace period or for other reasons)
The health plan must return a 2200D/E loop STC segment with the following:
- STC01-01 equals “P5” (meaning “Pending/Payer Administrative/System hold.”)
- STC01-02 equals “766” (Meaning “Services performed during a Health Insurance Exchange (HIX) premium payment grace period.”)
- STC02 equals (the effective date of the status)
- STC04 equals (Total Claim Charge Amount)
Note – other applicable STC segments can be returned as dictated by the business when additional status information is available.
005010X212 (277) Claim Status Response Detail – Adjudicated Claims
Adjudicated Claims
When the health plan receives a claim status request for a claim where:
- One or more of the service dates is within the grace period, and
- the claim has completed current adjudication (as paying or soft denied until the grace period is resolved)
The health plan must return a 2200D/E loop STC segment with the following:
- STC01-01 equals (the appropriate “Fx” Claim Status Category Code)
- STC01-02 equals “766” (Meaning “Services performed during a Health Insurance Exchange (HIX) premium payment grace period.”)
- STC02 equals (the effective date of the status)
- STC04 equals (Total Claim Charge Amount)
- Appropriate information in the remaining STC elements identifying paid amount, remittance and payment dates, and check/EFT number
Note – other applicable STC segments can be returned as dictated by the business when additional status information is available.
005010X228 – Health Care Claim Pending Status Information (277)
When the health plan sends claim status information on a complete list of claims pending in the payer’s adjudication system without requiring health care provider solicitation where:
- One or more of the service dates is within the grace period, and
- the claim is being pended and has not completed adjudication (either because of the grace period or for other reasons)
The health plan must return a 2200D/E loop STC segment with the following:
- STC01-01 equals “P5” (meaning “Pending/Payer Administrative/System hold.”)
- STC01-02 equals “766” (Meaning “Services performed during a Health Insurance Exchange (HIX) premium payment grace period.”)
- STC02 equals (the effective date of the status)
- STC04 equals (Total Claim Charge Amount)
Note – other applicable STC segments can be returned as dictated by the business when additional status information is available
.
Use of the 005010X228 is the ‘best practice’ for sending a list of pending claims.
005010X221 - Health Care Claim Payment/Advice (835)
When a health plan has received a claim with service dates within an active grace period, all remittance advice information related to that claim should identify the existence of the grace period as long as the grace period is still in effect. Details for multiple scenarios are provided below. In all cases, appropriate Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) must be included. Also, all other applicable 2100 and 2110 loop information must be reported as required by the ASC X12 Technical Report and applicable to the business of the specific claim or service. The actions to be taken once a grace period ends, either by payment of premium or failure to pay, are covered by existing requirements within the guide for Reversal and Correction and/or Overpayment Recovery, and are not included here.
Remittance Advice Detail - Pended or Soft Denial Claims
In the event a health plan is not supporting the 277CA, or is supporting the 277CA, but does not have the capability to identify the grace period at initial claim receipt AND/OR the health plan is not utilizing the 277 Pending Status Information transaction (005010X228) to provide a list of pending claims, then health plans that pend claims may choose to notify providers that the claim is in the second or third month of the grace period by using the Health Care Claim Payment/Advice (835). Even if a health plan is supporting the 277CA, they may not have edits that are able to identify the grace period at initial claim receipt, health plans that pend claims may choose to notify providers that the claim is in the second or third month of the grace period using the mandated Health Care Claim Payment/Advice (835). Note – This scenario can also be looked at as the health plan performing a soft denial – one where the decision isn’t final. When this happens, specific codes must be used to clearly identify the relationship of the claim to the grace period.
For claims that normally pay at the claim level (such as inpatient institutional claims where a DRG contract applies):
- Report the claim payment in 2100 loop CLP04 as zero
- Report the patient responsibility in 2100 loop CLP05 as zero
- Report a 2100 loop CAS segment where:
- CAS01 equals “OA”, meaning “Other Adjustment”
- CAS02 equals “257”, meaning “The disposition of the claim/service is pending during the premium payment grace period, per Health Insurance Exchange requirements. (Use only with Group Code OA)”
- CAS03 equals the total claim charge amount
- Report the related RARC codes in the 2100 loop MOA segment (positions 3, 4, 5, 6, 7) or MIA segment (positions 5, 20, 21, 22, 23), as
- Report RARC “N615”, meaning “Alert: This enrollee receiving advance payments of the premium tax credit is in the grace period of three consecutive months for non-payment of premium. Under the Code of Federal Regulations, Title 45, Part 156.270, a Qualified Health Plan issuer must pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period.”
- Report RARC “N617”, Meaning “This enrollee is in the second or third month of the advance premium tax credit grace period.”
For claims that normally pay at the service level (such as professional, dental and outpatient institutional claims):
- Report the claim payment in 2100 loop CLP04 as zero
- Report the patient responsibility in 2100 loop CLP05 as zero
- Report the related RARC codes in the 2100 loop MOA segment (positions 3, 4, 5, 6, 7) or MIA segment (positions 5, 20, 21, 22, 23), as applicable
- Report RARC “N615”, meaning “Alert: This enrollee receiving advance payments of the premium tax credit is in the grace period of three consecutive months for non-payment of premium. Under the Code of Federal Regulations, Title 45, Part 156.270, a Qualified Health Plan issuer must pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period.”
- Report RARC “N617”, Meaning “This enrollee is in the second or third month of the advance premium tax credit grace period.”
- Report a 2110 loop for each service line of the claim
- Report the service paid amount in 2110 loop SVC03 as zero
- Report a 2110 loop CAS segment where:
- CAS01 equals “OA”, meaning “Other Adjustment”
- CAS02 equals “257”, meaning “The disposition of the claim/service is pending during the premium payment grace period, per Health Insurance Exchange requirements. (Use only with Group Code OA)”
- CAS03 equals the service line charge amount
Remittance Advice Detail - Adjudicated Claims During the Grace period
Since the health plan is under no obligation to pend claims during the grace period, in some cases the health plan may choose to adjudicate and pay claims that fall in the grace period. This may be due to state prompt payment regulations or other requirements. When this happens, the fact that the claim is in the grace period must be conveyed to the provider using the coding of the 835.
- Report the related RARC codes in the 2100 loop MOA segment (positions 3, 4, 5, 6, 7) or MIA segment (positions 5, 20, 21, 22, 23), as applicable
- Report RARC “N615”, meaning “Alert: This enrollee receiving advance payments of the premium tax credit is in the grace period of three consecutive months for non-payment of premium. Under the Code of Federal Regulations, Title 45, Part 156.270, a Qualified Health Plan issuer must pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period.”
- Report RARC “N617”, Meaning “This enrollee is in the second or third month of the advance premium tax credit grace period.”
Optional Remittance Reporting - Grace Period First Month
Optionally, the health plan can indicate to the provider that the patient is/was in the first month of the premium payment grace period when paying a claim with dates of service in the first month.
- Report the related RARC code in the 2100 loop MOA segment (positions 3, 4, 5, 6, 7) or MIA segment (positions 5, 20, 21, 22, 23), as applicable
- Report RARC “N615”, meaning “Alert: This enrollee receiving advance payments of the premium tax credit is in the grace period of three consecutive months for non-payment of premium. Under the Code of Federal Regulations, Title 45, Part 156.270, a Qualified Health Plan issuer must pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period.”
- Report RARC “N616”, Meaning “Alert: This enrollee is in the first month of the advance premium tax credit grace period.”