CurrentCapital BluecrossPolicy N/A

Disability Certification of Adult Dependents

This document governs the process and required information for certifying an adult dependent's disability for coverage continuation under a subscriber's Capital BlueCross plan; it specifies responsibilities of the subscriber and the attending physician and the information to be submitted.

Policy Summary

PayerCapital Bluecross

PolicyDisability Certification of Adult Dependents

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionAttending physician (MD or DO) must complete Section II, sign, and submit medical records with the completed form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3form sections to be completed (Subscriber, Attending Physician, Subscriber employment history)

MD or DOprovider signatures accepted for Section II

prior to 26required onset of disability for dependent eligibility

medical recordssupporting documentation to submit with form

Coverage Certification Criteria

Policy Summary

PayerCapital Bluecross

PolicyDisability Certification of Adult Dependents

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionAttending physician (MD or DO) must complete Section II, sign, and submit medical records with the completed form.

SourceLink

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Coverage certification criteria

Information and documentation required to certify an adult dependent's disability for continued coverage:

ALL of the following

ALL of the following
- Subscriber completes Section I (personal and dependent information) and Section III if applicable (dependent employment history for the past 12 months).
  Include dependent's name, DOB, marital status, relationship to subscriber, travel ability, ways subscriber supports dependent, whether covered by other insurance, and Social Security benefits status.
ALL of the following
- Attending physician (MD or DO only) completes Section II including: diagnosis and concurrent conditions; if mentally impaired, define mental impairment in terms of mental age and/or IQ; define functional capacity in work, educational, or social settings; age at onset of continual disability; dates first and last seen for the diagnosis; brief care plan including frequency of visits/treatments; compliance with follow-up; anticipated duration of disability (less than 1 year, 1-3 years, or indefinitely).
  Physician must print name, degree, sign and date, and provide address. Signatures from other provider types will not be accepted.
ALL of the following
- Medical records must be submitted with the completed form; if applicable, submit Social Security benefits documentation.

ALL of the following

Subscriber must certify that the dependent is unmarried, incapable of self-support, dependent on the subscriber for more than half of support, and that the disability commenced prior to age 26.

Physician Completion and Documentation Requirements

Documentation Required

Physician must complete and sign Section II; subscriber pays any completion fee

Section II must be completed and signed by the attending physician (MD or DO only). Any fee charged by the attending physician for completing the form is the responsibility of the subscriber. Medical records must be submitted with the completed form.

Attending physician must complete Section II, including diagnosis, onset age, functional capacity, care plan, compliance, anticipated duration, and physician name, degree, signature, date, and address.
Subscriber is responsible for any fee charged by the attending physician for completion of the form.
Medical records must be submitted with the completed form.

Key Definitions

Attending physician (MD or DO only)

Accepted provider typesOnly an attending physician who is an MD or DO may complete and sign Section II; signatures from other provider types will not be accepted.

Required physician actionsComplete Section II including diagnosis, onset age, functional capacity, care plan, compliance, anticipated duration, and sign and date the form.

Fee responsibilityAny fee charged by the attending physician for completing the form is the responsibility of the subscriber.

Medical records requirementMedical records must be submitted with the completed form when the attending physician completes Section II.

Certification statementPhysician must certify that the information provided is correct to the best of their knowledge and authorize release of requested information.

Disabled dependent

Onset age requirementDependent's disability must have commenced prior to age 26.

Dependency criteriaDependent must be unmarried and incapable of self-support and dependent on the subscriber for more than half of his or her support.

Subscriber responsibilitiesSubscriber completes Sections I and III (if applicable) and certifies the dependent's marital status, dependency, and onset of disability.

Supporting documentationIf applicable, submit Social Security benefits form along with required medical records.