ACA plan resources for providers

A QHP is a plan that meets certain requirements under the Patient Protection and Affordable Care Act (ACA). A QHP is certified by the Centers for Medicare & Medicaid Services (CMS). Many QHPs have networks that are unique to these plans. Often, these networks have a smaller number of participating providers compared to our traditional networks.

Member ID cards will have “QHP” on the top right of the card and “Banner Networks” on the top middle. The product name and the plan name are on the right side of the card. There is a dedicated member services toll-free number.

Open Enrollment starts November 1, 2023 for all states, and ends January 15, 2024.​

​These plans will have an effective date of January 1, 2024 if a member enrolls and makes their first binder payment by December 15, 2023. If a member enrolls and makes the first binder payment between December 16, 2023 and January 31, 2024, their plan will be effective as of February 1, 2024. ​

Yes, the payer ID and claim address are the same for exchange plans and are provided below:

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

Banner|Aetna providers can check their status here: https://www.myplanportal.com/dsepublic/#/contentPage?page=providerSearchLanding&site_id=banneraetnaivlexchange

If you are registered with our Availity Provider portal, you can perform most electronic transactions in the portal, including submitting claims, checking claim status and patient benefits and eligibility, requesting pre-certifications, and submitting disputes and appeals. 

You will verify benefits or eligibility in the same way regardless of where the member purchased the plan. If you are registered with our Availity Provider portal, you can perform most electronic transactions in the portal, including submitting claims, checking claim status and patient benefits and eligibility, requesting pre-certifications, and submitting disputes and appeals.  

Yes, use our provider search online referral directory (links located below) to find providers in the exchange network. Remember, members have no out-of-network benefits on any plan except for emergencies.

Banner|Aetna Providers: https://www.myplanportal.com/dsepublic/#/contentPage?page=providerSearchLanding&site_id=banneraetnaivlexchange

We encourage all providers to review our provider manuals and associated materials.  They’re available online.

No, the existing claims filing limits will apply. 

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. Example:

Subscriber (Joseph Smith) = 320004841700

Dependent 1 (Jane Smith) = 320004841701

Dependent 2 (Daniel Smith) = 320004841702

Individual and family 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 and family insurance plans use Government Exclusion (GE) to coordinate with Medicare. GE is a method of determining Banner|Aetna’s payment when Medicare is primary for the member. Medicare payments are excluded from the total allowed charges. Banner|Aetna considers the allowance based on the member’s responsibility after Medicare has considered the claim. 

Banner|Aetna Individual and family insurance plan members are not required to select a PCP.

Effective 1/1/24 Banner|Aetna Individual and family insurance plan members do not need referrals.

There are no out of network benefits on any Banner|Aetna individual and family insurance plan except for emergencies. If Banner|Aetna 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 out of network if they are outside of the service area.

You can find formulary information at the link below:

2024 Formulary Information - Coming soon!

Claims will continue to be paid for 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 first 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 30-31 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, Banner|Aetna will pay you directly. Members have no out-of-network benefits on any plan in any state except for emergencies.

Banner|Aetna 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.