Referral Management Team Authorization Request Form Special Supplemental Benefit for the Chronically Ill (SSBCI) Form

Referral Management Team Authorization Request Form Special Supplemental Benefit for the Chronically Ill (SSBCI)

Special Supplemental Benefits for the Chronically Ill (SSBCI) are benefits that can be offered to HAP Medicare Advantage members who have one or more qualifying chronic conditions, who are at high risk for hospitalization or adverse health outcomes and who require intensive care coordination. Qualifying chronic conditions include, but are not limited to, cancer, cardiovascular disorders, chronic lung disorders, dementia and diabetes. Please see reverse side for more conditions. These benefits are in addition to the benefits that traditional Medicare covers and can include non-primarily health-related benefits so long as there is a reasonable expectation of improving or maintaining the health or overall function of the member. HAP Medicare Advantage members are eligible for the benefit based on qualifying clinical criteria of a chronic condition as determined and provided by their physician.

Please complete all fields below. Send completed, signed form by one of these options: • Fax: (313) 664-5916 • Email: RMT@hap.org

If you have any questions, email RMT@hap.org.

Member Information HAP member ID number (11 digits):

Member name (first and last):

Member’s date of birth:

Member’s phone number:

Provider Information NPI:

Name (first and last):

Phone number:

Fax number:

Address:

Contact person name:

Contact person phone number:

List of all known DIAGNOSIS CODE(S) ICD-10:
Event classification • Standard pre-service

Provider Signature Date

Complex Chronic Conditions

• Chronic heart failure

• Chronic lung disorders (limited to: asthma, chronic bronchitis, emphysema, pulmonary fibrosis, pulmonary hypertension)

• Chronic and disabling mental health conditions (limited to: bipolar disorders, major depressive disorders, paranoid disorder, schizophrenia, schizoaffective disorder)

• Chronic alcohol use disorder and other substance use disorders

• Autoimmune disorders (limited to: polyarteritis nodosa, polymyositis rheumatica, polymyositis, systematic lupus erythematosus)

• Cancer (excluding pre-cancer conditions or in situ status)

• Chronic Cardiovascular disorders (limited to: cardiac arrhythmias, coronary artery disease [CAD], peripheral vascular, chronic venous thromboembolic disorder)

• Dementia

• Diabetes

• Chronic gastrointestinal disease

• Chronic kidney disease (CKD) (CKD requiring end stage renal disease (ESRD))

• Severe hematologic disorders (limited to: aplastic anemia, hemophilia, immune thrombocytopenic, purpura, myelodysplastic syndrome, sickle-cell disease [excluding having the sickle-cell trait], chronic venous thromboembolic disorder)

• HIV/AIDS

• Neurologic disorders (limited to: amyotrophic lateral sclerosis (ALS), epilepsy, extensive paralysis (i.e., hemiplegia, quadriplegia, paraplegia, monoplegia), Huntington’s disease, multiple sclerosis, Parkinson’s disease, polyneuropathy, spinal stenosis, stroke related neurologic deficit)

• Stroke

Health Alliance Plan (HAP) has HMO, HMO C-SNP, HMO-POS, PPO plans with Medicare contracts. HAP Medicare Complete Duals (HMO D-SNP) and HAP Medicare Complete Assist (PPO D-SNP) are Medicare health plans with a Medicare contract and a contract with the Michigan Medicaid Program. Enrollment depends on contract renewals.

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