Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyExcellus Disability Extension Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentExcellus Health Plan IncPolicy 10.01.11

    Disability Determination for Extension of Benefits After Coverage Termination

    Customize your policy alerts

    Sign up for excellus_health_plan_inc Policy 10.01.11 alerts

    Get alerted when Policy 10.01.11 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy governs whether a former member was totally disabled before and on the date coverage ended and may qualify for extended benefits, subject to the applicable subscriber contract and coverage limitations.

    Policy Summary
    PayerExcellus Health Plan Inc
    PolicyDisability Determination for Extension of Benefits After Coverage Termination
    Policy CodePolicy 10.01.11
    Change TypeAnnual review — no material change
    Effective DateAugust 20, 2026
    Next Review DateAugust 1, 2027
    Key ActionThe treating physician must submit certification and evidence that the former member’s total disability existed before coverage termination.
    SourceLink
    POLICY UPDATE CHANGES

    The policy underwent an annual review on August 20, 2026, with policy intent unchanged.

    Medical Director reviewDisability determination
    31 daysGroup coverage timing
    12 monthsMinimum group extension
    12 monthsIndividual extension limit

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Related services onlyCovered services
    NoneSpecific codes listed

    Eligibility and Benefit Extension Criteria

    General eligibility for extension of benefits

    An extension of benefits may be considered when all core eligibility conditions are met.

    Core eligibility for extension

    • Disability timing

      • The former member was totally disabled before and on the date coverage terminated.Before and on termination date

    • Provider submission

      • The treating physician submitted certification of the former member's total disability and evidence that the disability existed before termination.

    • Covered-period care

      • The former member received services or care for the illness, condition, or injury causing total disability while covered under the subscriber contract.

    • Contract eligibility

      • The former member is otherwise eligible for an extension of benefits under the applicable subscriber contract.

    Group coverage termination

    For group coverage, benefits are available under the applicable termination circumstance when the stated conditions are met.

    Qualifying group termination circumstances

    • Termination of employment, eligibility, or group contract

      • The former member's coverage was terminated because of termination of employment, termination of eligibility, or termination of the group contract.
      • A hospital stay commenced or surgery was performed within 31 days after coverage ended.Within 31 days of coverage termination
      • The hospital stay or surgery treated the injury, sickness, or pregnancy that caused the total disability.

    • Termination of active employment

    Individual coverage termination

    Individual-policy benefits extend when the former member is determined to be totally disabled as of the coverage termination date.

    • The former member was covered under an insured individual policy.
    • The former member was determined to be totally disabled as of the date coverage terminated.
    • Benefits are used only to treat the total disability.
    • The benefit extension applies for 12 months or, if earlier, until the total disability ends.12 months or earlier end of total disability

    Extended benefits are limited to covered services directly related to the total disability. Treatment unrelated to the injury, sickness, or pregnancy that caused the disability is not included.

    The Health Plan will not provide benefits exceeding the amount that would have been available if the member had remained covered under the applicable subscriber contract. Extended benefits also end when available benefits are exhausted, the member is no longer totally disabled, or the applicable time period or extended services have ended.

    Services are contract dependent. If the member’s product does not cover a service, medical policy criteria do not apply to that benefit.

    Extension of benefits for total disability after disenrollment from Medicare is not addressed in the cited National or Regional Medicare coverage determinations or policies.

    Coding Information

    CPT CodesCPT
    No codes listed
    HCPCS CodesHCPCS
    No codes listed
    ICD10 CodesICD-10
    No codes listed

    Documentation and Decision Considerations

    Documentation Required

    Treating Physician Disability Certification

    To request an extension-of-benefits determination, the treating physician must certify the former member's total disability at the time coverage terminated and submit evidence that the disability existed before termination.

    • Certification must address total disability both before and on the date of termination.
    • Supporting evidence should establish that the qualifying disability was present before coverage ended.
    Documentation Required

    Medical Records for Medical Director Review

    The Health Plan Medical Director determines whether the former member was totally disabled before and on the termination date. The determination is based on review of the former member's medical records and, when necessary, discussion with the treating physician or designee.

    • Submit relevant medical records for Medical Director review.
    • The Medical Director is guided by the Social Security Administration's Disability Evaluation under Social Security (Blue Book) criteria.

    Policy Background

    This policy addresses administrative continuation of coverage after a member’s coverage ends, rather than a condition-specific clinical treatment policy. A Health Plan Medical Director determines whether the former member was totally disabled before and on the coverage termination date, based on medical records and, when necessary, discussion with the treating physician or designee. If approved, extended benefits are limited to covered treatment for the condition causing the total disability and remain subject to the applicable subscriber contract.

    Key Terms

    Total disability
    DefinitionAn individual is totally disabled when the Health Plan Medical Director determines that the individual was totally disabled before and on the date coverage terminated.
    Extension of benefits
    DefinitionBenefits provided after coverage termination for covered services directly related to the total disability, when the former member otherwise qualifies under the applicable contract and policy provisions.
    E/I
    AbbreviationExperimental/Investigational.
    NMN
    Policy Summary
    PayerExcellus Health Plan Inc
    PolicyDisability Determination for Extension of Benefits After Coverage Termination
    Policy CodePolicy 10.01.11
    Change TypeAnnual review — no material change
    Effective DateAugust 20, 2026
    Next Review DateAugust 1, 2027
    Key ActionThe treating physician must submit certification and evidence that the former member’s total disability existed before coverage termination.
    SourceLink
    On This Page
    Eligibility and Benefit Extension CriteriaCoding InformationDocumentation and Decision ConsiderationsPolicy BackgroundKey Terms
    Group coverage providing major medical-type benefits ended because the former member was no longer actively employed.
  1. Coverage for services in connection with the total disability is not provided under another health plan.
  2. The covered services treat the injury, sickness, or pregnancy that caused the total disability.
  3. The extension applies during the period of total disability for at least 12 months from the date coverage ended.At least 12 months from coverage termination

    4. Unsupported block type: billing_rule

    Denial Risk

    Disability Did Not Predate Termination

    An extension of benefits is available only when the total disability existed before and on the date coverage terminated. If the documentation does not establish that timing, the provider should respond to requests for supporting evidence; services are not eligible for the disability extension unless the Medical Director makes the required determination.

    • The treating physician must provide evidence that the total disability predated termination.
    • The Medical Director determines whether total disability existed before and at termination.
    Denial Risk

    Services Unrelated to Qualifying Disability

    Even when an extension is approved, benefits are limited to covered services directly related to the injury, sickness, or pregnancy that caused the qualifying total disability. Services unrelated to that disability may be denied under the extension.

    • The former member must have received care for the illness, condition, or injury causing the disability while covered under the subscriber contract.
    • Services must be covered under the applicable contract and directly related to the qualifying disability.
    Denial Risk

    Extension Period or Disability Has Ended

    Extended benefits end when the available benefits are exhausted, the Medical Director or designee determines that the member is no longer totally disabled, or the applicable maximum period or extended services end.

    • For an insured individual policy, the extension lasts 12 months or, if earlier, until the total disability ends.
    • Check the contract for the applicable maximum period and service limitations.
    Billing Rule

    Contract Benefit Limit Exceeded

    The Health Plan will not provide more benefits through the extension than would have been available if the member had remained covered under the continuing contract.

    • Confirm remaining contract benefits before submitting claims under the extension.
    • Claims exceeding the applicable contract benefit limit are not payable.
    Denial Risk

    Service Excluded by Member Contract

    Services are contract dependent. If the member's product excludes a service, the medical policy criteria do not apply and the service is not covered under that product.

    • Verify coverage under the member's contract before applying medical policy criteria.
    • A service excluded by the contract may be denied regardless of whether medical policy criteria are met.
    Denial Risk

    Medicare DSNP Service Not Covered

    For a Medicare HMO-Dual Special Needs Program (DSNP) product, if the Medicare product does not cover the specific service, refer to the Medicaid product coverage line. Medical policy criteria apply only when the applicable product covers the service and no controlling Medicare coverage decision exists.

    • Check for a national or local Medicare coverage decision when the Medicare product covers the service.
    • Do not apply Medicare medical policy criteria to a service the Medicare DSNP product does not cover.
    AbbreviationNot medically necessary/appropriate.