Skip to Main Content

Reminder to Verify Ambetter from Arizona Complete Health Member Eligibility

Date: 10/28/25

Reminder: Verify Ambetter from Arizona Complete Health Member Eligibility

With changes coming to the 2026 Health Insurance Marketplace and open enrollment beginning on November 1, it’s important to verify member eligibility.

_________________________________________________________

Grace Periods & Claim Status

Premium Payment Grace Periods:

Members enrolled in a Marketplace health plan are responsible for completing their premium payments each month. Members that do not make their premium payments in a timely manner enter a Grace Period, which begins with the first month a payment is missed.

  • With APTC: 90-day Grace Period for premium non-payment before the policy is terminated provided the member has paid at least one month’s premium
  • Without APTC: One-month Grace Period, typically 31 days

Claim Handling During Grace Period:

  • No APTC: All claims during grace period are pended until payment is made
  • With APTC:
    • Initial phase: Claims may be paid
    • Later phase: Claims are pended until payment is made

If the member does not pay by the end of the grace period, coverage is terminated, and claims are denied

_________________________________________________________

How to Check Eligibility & Claim Status

Use Availity Essentials or our secure portal to check:

  • Member Eligibility Status
  • Premium Paid Through Date
  • Claims Paid Through Date

Eligibility Status Definitions:

  • Active: Premium paid; member in good standing.
  • Active – Pending Investigation (Availity only): Member behind on payments
  • Delinquent (health plan secure portal only): Member behind; claims may still be paid
  • Suspended (health plan secure portal only): Member behind; claims likely not paid
  • Inactive: Coverage terminated

Key Dates:

  • Premium Paid Through Date: Last date premium was paid
  • Claims Paid Through Date: Last date claims will be considered for payment. Claims submitted after this date will be pended until the member pays any outstanding premium balances or the grace period ends. Claims submitted for dates of service after this date are at risk for nonpayment/rejection should the member not return to good standing prior to the end of the grace period.

_________________________________________________________

Provider Billing Guidance

If a member is not in good standing:

  • You may collect full billed charges for covered services rendered
  • If the member pays and coverage is reinstated, submit the claim
  • If the claim is paid, you must reimburse the member per your Provider Agreement.

_________________________________________________________

Claim Scenarios

Scenario 1 Claim Considered for Payment

  • Date of Service: Sept. 1, 2025
  • Member Receives APTC: Yes
  • Member Eligibility Status: Active
  • Premium Paid Through Date: Sept. 30, 2025
  • Claims Paid Through Date: Oct. 31, 2025
  • Claim Status: Considered for Payment

Member is in good standing, and the claim is considered for payment. The Date of Service is prior to the Premium Paid Through Date and Claims Paid Through Date, which is 30 days after the Premium Paid Through Date because the member receives an APTC.

Scenario 2 Claim Considered for Payment

  • Date of Service: Sept. 1, 2025
  • Member Receives APTC: No
  • Member Eligibility Status: Active
  • Premium Paid Through Date: Sept. 30, 2025
  • Claims Paid Through Date: Sept. 30, 2025
  • Claim Status: Considered for Payment

Member is in good standing, and the claim is considered for payment. The Date of Service is prior to the Premium Paid Through Date and Claims Paid Through Date. The Premium Paid Through Date and Claims Paid Through Date are the same because the member does not receive an APTC.

Scenario 3 Claim Pending

  • Date of Service: Sept. 1, 2025
  • Member Receives APTC: No
  • Member Eligibility Status: Active – Pending Investigation or Delinquent
  • Premium Paid Through Date: Aug. 30, 2025
  • Claims Paid Through Date: Aug. 30, 2025
  • Claim Status: Pending

Member is not in good standing and has entered the Grace Period. The claim is placed in a pending status because the member is behind in their premium payment, does not receive an APTC, and the Claims Paid Through Date is in the past. This claim will be considered for payment only if the outstanding premium balance is paid in full during the Grace Period. If the outstanding balance is not paid before the end of the Grace Period, the claim will be denied.

Scenario 4 Claim Considered for Payment

  • Date of Service: Sept. 1, 2025
  • Member Receives APTC: Yes
  • Member Eligibility Status: Active – Pending Investigation or Delinquent
  • Premium Paid Through Date: Aug. 30, 2025
  • Claims Paid Through Date: Sept. 30, 2025
  • Claim Status: Considered for Payment

Member is not in good standing and has entered the initial phase of the Grace Period. The claim is considered for payment even though the Date of Service is after the Premium Paid Through Date because the member receives an APTC and Claims Paid Through Date is in the future. The member remains responsible for the outstanding premium payment.

Scenario 5 Claim Pending

  • Date of Service: Sept. 1, 2025
  • Member Receives APTC: Yes
  • Member Eligibility Status: Active – Pending Investigation or Suspended
  • Premium Paid Through Date: July 31, 2025
  • Claims Paid Through Date: Aug. 30, 2025
  • Claim Status: Pending

Member is not in good standing and is in the latter phase of the Grace Period. The claim is placed in a pending status. While the Claims Paid Through Date is after the Premium Paid Through Date because the member receives an APTC, the Claims Paid Through Date is prior to the Date of Service. The claim will be considered for payment only if the outstanding premium balance is paid in full during the Grace Period. If the outstanding balance is not paid, the claim will be denied.

Scenario 6 Claim Denied

  • Date of Service: Sept. 1, 2025
  • Member Receives APTC: Yes
  • Member Eligibility Status: Inactive
  • Premium Paid Through Date: May 31, 2025
  • Claims Paid Through Date: June 30, 2025
  • Claim Status: Denied

Member did not pay the outstanding balance, the Grace Period has expired, and coverage is terminated. The claim is denied because the member is no longer covered by the health plan.

_________________________________________________________

Questions?

Contact your Provider Engagement Account Manager or email us:  AzCHProviderEngagement@azcompletehealth.com.