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I am a provider or physician.

Health Care Reform brings changes for both patients and providers. The links below will give you the most recent information about upcoming changes.

Electronic Billing and Claims Processing Changes
We are excited to provide improved billing and claims processing to help you better manage your practice.

270/271(Member Eligibility) and 276/277 (Claim Status)  Electronic Transaction Sets:

  • We are fully HIPAA-compliant with these transaction sets
  • Real-time information relative to member benefits and out-of-pocket costs can be obtained via our 270/271 Member Eligibility HIPAA-compliant transaction sets.
  • To sign up to use these electronic exchanges, please review online Companion Guides.

835/Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT)

  • Updated 835/ERA transactions will be available January 1, 2014
  • EFT and claim payment/remittance advice transactions will also be available January 1, 2014
  • Enrollment information for these transactions is coming soon

Plan and Benefit Changes

The ACA’s Essential Health Benefits requirements change certain member plan and benefit structures.  Changes in the method used to calculate member maximum out-of-pocket limits and a split primary/specialty care co-pay option are being implemented. We are also planning an update to the member identification card.

The benefits changes are not universal and will be based upon the plan type (individual, small group, large group, etc) a member is covered under. The benefits listed below may change based upon the plan type:

  • Pediatric vision
  • Hearing aids
  • Bariatric services
  • Infertility services
 
  • Temporomandibular disorder
  • Clinical trial coverage definition 
  • Home Health and therapy visit limits (PT/OT/ST)    
  • Habilitative services

90-Day Member Premium Grace Period

The ACA requires DHP to allow a 90-day premium payment grace period to members receiving an Advance Premium Tax Credit (APTC) for insurance purchased using the new Federally Facilitated Marketplace. This new requirement changes how we will process claims received while this anticipated small subset of members is within their premium grace period.  Additional information on how such claims will be processed will be provided in November.

Patient Resources
We are dedicated to helping you provide the highest quality of care for your patients. You are often the first point of contact and may receive questions about how health care reform will affect your patient. Feel free to refer your patients to the information below.

Please see our Resource Guide for HCR and Benefit Changes to learn more.

Can I shop on the Marketplace Health Care Reform & You
Helping individuals and employer groups purchase insurance Helpful Links Common Questions
Individual & Family Plans Health Care Reform & You