CurrentPremera BluecrossPolicy N/A

Certificación de dependiente discapacitado

Describe el formulario y el proceso para certificar que un dependiente adulto tiene una discapacidad que le permite continuar en la cobertura del plan más allá del límite de edad; aplica a suscriptores y médicos que solicitan continuidad de cobertura.

Policy Summary

PayerPremera Bluecross

PolicyCertificación de dependiente discapacitado

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPhysician must complete, sign, and attest to Section 5 including ICD-10 diagnosis and date of last exam within the past year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-5Secciones

SSDI/SSI/OrdenDocumentos aceptados

Suscriptor y médicoFirma requerida

Fax disponibleEnvío

Disabled Dependent Coverage Criteria

Disabled dependent coverage criteria and required documentation

Eligibility for continuation of coverage requires meeting disability criteria and submitting specified documents and attestations.

ALL of the following

Dependent was declared disabled before reaching the plan's limiting age
See attestations and evidence requirements
Dependent is incapable of self-sustaining employment due to the disability
Dependent is primarily dependent on the subscriber (and/or spouse) for support and maintenance
The inability to find employment or a reduction in workforce alone does NOT qualify for continuation of coverage

Policy Summary

PayerPremera Bluecross

PolicyCertificación de dependiente discapacitado

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPhysician must complete, sign, and attest to Section 5 including ICD-10 diagnosis and date of last exam within the past year.

SourceLink

On This Page

Supporting documentation — choose ONE of the following paths

Social Security Disability path: Dependent has been declared disabled by the Social Security Administration; attach SSDI Award letter and most recent SSI statement as applicable; complete Section 3A and sign subscriber signature line
Attach SSDI award letter and SSI documents where applicable
Legal Guardianship path: Dependent has been placed in legal guardianship by court order; attach active legal guardianship court order and related documents; complete Section 3B and sign subscriber signature line
Attach court order and supporting statements
No SSDI or guardianship available: If neither SSDI nor guardianship documents are available, sign the subscriber statement and proceed to Sections 4 and 5 with physician testimony (physician must complete Section 5)
Subscriber must sign and obtain physician completion of Section 5

ALL of the following

A physician must complete, sign, and attest Section 5; all fields are required
Physician must provide diagnosis (ICD-10), level and duration of disability, and date of last exam within the past year as part of Section 5
If dependent has only SSI and not SSDI, physician must complete Section 3 (physician declaration) per instructions
See Section 3 and Section 5 instructions

Physician & Submission Actions

Documentation Required

Physician must complete and sign Section 5

Physician must complete, sign, and attest to Section 5, including the date of the patient’s last exam (application date and last exam must be within the past year) and provide the diagnosis causing the disability using ICD-10 and standard nomenclature. The physician must also indicate level and duration of disability and certify the statements by signature.

Complete all fields in Section 5 and sign the attestation.
Provide date of last exam — application date and last exam must be within the past year.
Record diagnosis causing disability with ICD-10 code and standard nomenclature.
Indicate level of disability, whether temporary or permanent, and estimated duration if temporary.

Note

Submit completed form and supporting documents by mail or fax

Return the completed, signed form and any supporting documents to Premera Membership & Billing by mail or fax as instructed on the form.

Mail to: Premera Blue Cross HMO Membership & Billing, PO Box 327, MS 737, Seattle, WA 98111-0327.
Fax to: 888-251-7319.

Key Definitions

Disabled dependent

DefinitionDependent who became disabled before reaching the plan's limiting age and is unable to engage in employment to support themselves due to a physical or mental disability.

Condition for continuationDisability must have begun before the limiting age (after age 25).

Employment inabilityInability to find employment or workforce reduction alone does NOT qualify for continuation of coverage.

Who may submitSubscriber or the dependent's physician may provide the requested information on the Disabled Dependent Certification form.

Required signatoriesSubscriber must complete required sections and sign the attestation; a certified physician must complete and sign applicable fields when required.

SSDI / SSI

SSDISocial Security Disability Insurance — copy of SSDI award letter should be included when applicable.

SSISupplemental Security Income — if the dependent has only SSI and not SSDI, the dependent's physician must complete Section 3 (Physician's Statement).

Alternative documentationActive court order (e.g., legal guardianship) may be submitted when applicable.

No SSDI/guardianship availableIf SSDI award letter or court order is not available, a physician's testimony must be completed and signed.

OpenPayer

Certificación de dependiente discapacitado

Disabled Dependent Coverage Criteria

Diagnosis Coding

Physician & Submission Actions

Key Definitions