Provider FAQs: Individual health plans

No, the existing claims filing limits will apply. For more information on timely filing standards, state by state, check out our insurance regulations by state resources on Aetna.com

The ID number listed on the member ID card (the one ending in “00”) is the member ID for the subscriber. When submitting inquiries or other requests (such as a claim or prior authorization request) for someone other than the subscriber, replace the “00” with the last two numbers that pertain to that other person.

Here’s an example:

Subscriber (Joseph Smith) - 320004841700

Dependent 1 (Jane Smith) - 320004841701

Dependent 2 (Daniel Smith) - 320004841702

Individual insurance plans do not coordinate with any insurance other than Medicare (for example, if someone had coverage under a Commercial plan, they would not qualify for the individual insurance plan). If the member is eligible 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’s payment when Medicare is primary 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.

Most Aetna CVS Health ACA plan members will be auto-assigned a PCP except in Missouri, North Carolina and Virginia (Aetna members in Roanoke and Richmond). If they contact customer service, the selection can be made at that time, and then we will mail them a new ID card.

There are no OON benefits on any Aetna CVS Health individual plan in any state except for emergencies. If Aetna CVS Health approves something, it would be at the INN benefit and at a contracted rate (if broad network provider), or LOA negotiated. MinuteClinic^® locations and some labs have a national network, so they are not considered OON if they are outside of the service area.

Simply select your location below to find formulary information.

• Arizona (Banner|Aetna)
• Florida
• Georgia
• Missouri
• Nevada
• North Carolina
• Texas
• Northern Virginia (Innovation Health)
  
• Richmond and Roanoke, Virginia
  

We will continue to pay any claims that occur during the first month of non-payment.

The grace period is different between members who receive premium subsidies (Advance Premium Tax Credit) and those who don’t:

• For members who receive premium subsidies, there is a 90-day grace period.  At the start of the second month of non-payment, claims will be pended until payment is received in full.  If the member doesn’t pay, their termination date will be the last day of the “free” month (they get the first month “free’) and any claims paid after the termination date would be an overpayment.
• For members who don’t receive premium subsidies, the grace period requirements vary between 30 and 31 days. If the member doesn’t pay, their termination date will be the last day of the prior month that the premium was paid, and any claims paid after the termination date would be an overpayment.

We'll process the claim in accordance with the 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.

Aetna CVS Health will provide reimbursement as outlined in your current contract, as applicable, or in a specific QHP rate schedule, should Network have arranged one with you (usually for facilities only). Refer to your contract agreement/amendment for details.