Aetna CVS Health® plans: FAQs for providers

A QHP is a plan that the Centers for Medicare & Medicaid Services (CMS) certifies and meets certain requirements under the Patient Protection and Affordable Care Act (ACA). QHPs have networks that are unique to ACA plans. QHP plans are also called exchange plans or Marketplace plans.

The date your patient’s plan starts depends on their sign-up date.

In most states, Open Enrollment runs from November 1 to January 15. Coverage usually starts on the first day of the month following the plan selection. For example, if your patient selects a plan on December 31, their coverage will start on January 1. California and New Jersey residents can enroll until January 31 for coverage starting February 1.

Your patients may qualify to get coverage outside of the Open Enrollment window if they’ve had a big life change or one coming up, such as a new child or the loss of their health plan.

To check a patient’s eligibility, use our Availity® online portal.

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, you can call Availity Client Services at 1-800-282-4528 for help.
• If your practice is new to Availity: Find instructions to set up your Availity account.

You can use our online provider search.
 

• Aetna CVS Health providers: Check participation status.
• Banner|Aetna providers: Check participation status.
• Innovation Health providers: Check participation status.

We encourage you to review our provider manuals and other helpful resources. They’re available online.

You can use the Provider Data Management (PDM) tool in the Availity® provider portal to update and maintain your profile. To learn more about the Availity portal, sign up for training and find resources like our PDM quick reference guide, visit our Availity resource center.

Exchange members have “QHP” on the upper right corner of their member ID card. The company logo is on the upper left corner of the card.

• The left side of the card shows the subscriber’s name, ID number, plan number, PCP election and covered dependents, if any. You can also find drug pharmacy details.
• The right side of the card shows the product name, plan name, copay information (e.g., PCP and specialist) and payer ID.
• The back of the card shows specific contact information for ways to reach us, including a toll-free Member Services number.

Here’s an example of a member ID card.

No matter where the member bought their plan, you will verify benefits, eligibility and the PCP on record 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, you can call Availity Client Services at 1-800-282-4528 for help.
• If your practice is new to Availity: Find 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 for 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 don't have out-of-network benefits with any plan, in any state, except for emergencies.

These specialties allow direct access* and may not require referrals. Some services may require precertification.*

• Behavioral health
• Durable medical equipment
• Gynecology care (obstetrician/gynecologist)
• Home health care
• Hospital ambulatory surgery
• Hospital outpatient
• Mid-level practitioners (e.g., 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 provider search.
 

• Search Aetna CVS Health providers
• Search Banner|Aetna providers
• Search Innovation Health providers
  
  

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

Individual insurance plans use Government Exclusion (GE) to coordinate with Medicare. GE is a way to determine Aetna payment when Medicare is the member’s primary insurance. 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.

Aetna CVS Health plans don’t include out-of-network benefits in any state, except for emergencies. When we approve coverage, it’s at the in-network benefit and at a contracted rate (for broad network providers) or negotiated in a letter of agreement.

MinuteClinic® locations and some labs have a national network. We don't consider them out of network even if they're outside of the service area.

To find state formulary information and other drug coverage resources, choose 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 and reimbursement resources.

We encourage electronic claims submission. Prefer to mail a claim? Use one of these addresses:

• 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 current claims filing limits are the same. For guidance on filing standards, go to insurance regulations by state.

That means we’ll continue to pay claims from the first month of non-payment. This grace period is different for members who receive premium subsidies and those who don’t:

• For on-exchange members who receive premium subsidies: There is a 90-day premium payment grace period. 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 the premium and we cancel coverage, we deny claims in months two and three of the grace period. This is for all states except Texas.
• For Texas members: We process claims during the 90-day grace period. If the member doesn’t pay the premium and we cancel coverage, we may recover overpayment for claims we paid in months two and three of the 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 the premium, the plan termination date is the last day of the prior month they did pay. If we pay claims after coverage ends, we may recover overpayment.
• For California members: The grace period is 30 days. If the member doesn’t pay the premium, coverage will likely be cancelled. Claims we pay during the grace period won’t have overpayment recovery.
   

Need to find out if a member is in a grace period?

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

We process out-of-network claims based on the member’s plan benefits. If the member has assigned benefits, we pay you directly. Members don’t have out-of-network benefits with any plan, in any state, except for emergencies.

We’ll reimburse you as outlined in:

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

For details, check your contract agreement or amendment.