ACA plan resources 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 can also be referred to as Exchange Plans or Marketplace Plans.

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

The date your patient’s plan starts depends on their sign-up date. In Arizona, 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 10, their coverage will start on January 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: Set up your Availity account.

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. However, if you prefer to mail a claim, you can use the address below:

Banner|Aetna
PO Box 14079
Lexington, KY 40512- 4079

You can use our online provider search. 

Banner|Aetna providers: Check participation.

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: Set up your Availity account.

Referrals are not required; however, members must access in-network providers to receive coverage, except for emergencies.*

To find providers in the exchange network, use our provider search.


* Some services and equipment require prior approval, including durable medical equipment, hospital ambulatory surgery, hospital outpatient and radiology and pathology and lab. To confirm benefits, you can call your provider support team at 1-888-632-3862 (TTY: 711). 

We encourage all providers to review our provider manuals and other helpful resources.

• 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 you can sign up for training and find resources like our PDM quick reference guide.
• Visit the Availity resource center to get started.

No. The current claims filing limits are the same. 

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) = 10XXXXXXXX00

Dependent 1 (Jane Smith) = 10XXXXXXXX01

Dependent 2 (Daniel Smith) = 10XXXXXXXX02

ACA individual insurance plans only coordinate with Medicare coverage. If the member is eligible for Medicare and elects 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 Banner|Aetna payment when Medicare is the primary insurance for the member. We exclude Medicare payments from the total allowed charges. Banner|Aetna considers the allowance based on the member’s responsibility after Medicare has considered the claim.

Banner|Aetna does not require members to assign a PCP.

Banner|Aetna individual & family plan members do not require referrals.

There are no out-of-network benefits with any Banner|Aetna individual & family plan, in any state, except for emergencies. If Banner|Aetna 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. We don’t consider them out of network even if they are outside of the service area.

To find state formulary information and other drug coverage resources, please click on a link:

• 2024 Drug Search
• 2025 Drug Search

That means we’ll continue to pay any claims from the first month of non-payment. However, the grace period is different for members who receive premium tax credits (Advance Premium Tax Credit) and those who don’t:

For on-exchange members who receive premium tax credits: There is a 90-day premium payment grace period. In all states except Texas, 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 their premium and we terminate coverage, claims for services in months two and three of the grace period are denied.

To determine if a member is in a grace period, log in to Availity^® to check benefits and eligibility. You'll 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 varies between 30 and 31 days. If the member doesn’t pay, their coverage termination date is the last day of the prior month that they did pay. Any paid claims with dates of service after coverage is terminated are subject to overpayment recovery.

We process out-of-network claims according to plan benefits. If the member has assigned benefits, Banner|Aetna will pay you directly. However, 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.