CurrentCapital BluecrossPolicy N/A

Disability Certification of Adult Dependents

This document is a Capital Bluecross administrative form and instructions for certifying disability of an adult dependent to continue dependent coverage; it governs completion requirements by subscribers and attending physicians and the supporting documentation needed.

Policy Summary

PayerCapital Bluecross

PolicyDisability Certification of Adult Dependents

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionAttending physician (MD or DO) must sign and submit medical records (and Social Security benefit forms if applicable).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Sections I–IIIform sections to be completed

MD/DOrequired signer

Social Security docssupporting documentation

Employment historysubscriber must provide

Physician fee possibleform completion cost

Required Documentation to Certify Disability

Policy Summary

PayerCapital Bluecross

PolicyDisability Certification of Adult Dependents

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionAttending physician (MD or DO) must sign and submit medical records (and Social Security benefit forms if applicable).

SourceLink

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Required documentation and attestations

Information and evidence required to certify an adult dependent's disability and continued eligibility:

ALL of the following

Provide subscriber name, group number, identification number, and address
Provide dependent full name, date of birth, relationship to subscriber, and marital status

ALL of the following

Indicate whether dependent can perform activities of daily living (bathing, dressing, eating)
Indicate whether dependent can travel unattended
Describe specific ways subscriber supports or assists the dependent
State age at which the dependent's disability occurred and why benefits continuation is requested

Employment and other coverage

If dependent has been employed in past 12 months, list employer(s) with addresses, dates employed, and hours worked per week (Section III)
If dependent is covered under other hospital or medical coverage, provide insurer name, group, and identification number

Social Security documentation (if applicable)

Indicate whether dependent is receiving Social Security benefits
If yes, provide effective date, copy of Notice of Award, and most recent notice of benefit changes

ALL of the following

Attending physician must be MD or DO; signatures from other provider types will not be accepted
Submit medical records with the completed form
Provide diagnosis and concurrent conditions, dates first and last seen, brief care plan including frequency of visits and treatments, and statement of compliance with recommendations
If mentally impaired, define mental impairment in terms of Mental Age and/or IQ and describe functional capacity in work, educational, or social settings
Duration of disability
- Indicate anticipated duration: Less than 1 year

ALL of the following

Subscriber must certify that dependent is unmarried, incapable of self-support, dependent for more than half of support, and that disability commenced prior to age 26
Subscriber and physician must certify accuracy and authorize release of information
Warning that failure to follow instructions or submission of false information may result in denial of coverage or penalties
Any fee charged by the attending physician for completion of this form is the responsibility of the subscriber

Signature, Submission, and Documentation Requirements

Documentation Required

Physician signature and supporting documentation required

The form must be signed by the attending physician (MD or DO); signatures from other provider types are not accepted. Medical records must be submitted, and if applicable, Social Security benefits forms must be included. Failure to follow these instructions may result in a denial of coverage.

Required signer: Attending physician (MD or DO) only — other provider types' signatures will not be accepted.
Submit supporting medical records with the form.
If the dependent receives Social Security benefits, include the applicable Social Security benefits form.
Noncompliance may result in denial of coverage.

Key Definitions

inv-03: Incapable of self-support — Definition

Core definitionAn unmarried dependent who is incapable of self-support, is dependent on the subscriber for more than half of his or her support, and whose disability commenced prior to age 26.

Subscriber attestationSubscriber must certify that the dependent is unmarried, incapable of self-support, and dependent for more than half of support.

Supporting evidenceMedical records must be submitted with the completed form as part of verifying incapacity to self-support.

Related requirementIf receiving Social Security benefits, provide effective date, Notice of Award, and most recent notice of benefit changes.

inv-04: Mental impairment definition

Mental impairment criteriaIf mentally impaired, define mental impairment in terms of Mental Age and/or IQ.

Functional capacity assessmentAlso define the dependent's functional capacity in work, educational, or social settings (describe limitations and abilities).

Clinical documentationAttending physician must provide diagnosis, concurrent conditions, dates first and last seen, care plan, and anticipated duration of disability.

Physician responsibilityMedical records must accompany the completed form; attending physician may charge a fee to the subscriber for completion.