Special Supplemental Benefits for the Chronically Ill Condition Verification for 2027
Special Supplemental Benefits for the Chronically Ill (SSBCI) are benefits offered to members who meet eligibility criteria and are in one of the following plans:
• HAP Medicare Diabetes and Heart (HMO C-SNP)
• HAP Medicare Complete Duals (HMO D-SNP)
• HAP Medicare Complete Assist (PPO D-SNP)
Special Investigations Unit Protecting Program Integrity and Healthcare Resources
The Health Alliance Plan by Henry Ford Health Special Investigations Unit (SIU) is a specialized department dedicated to protecting healthcare resources. It ensures healthcare services are billed, documented and reimbursed appropriately.
The SIU plays an important role in identifying, investigating, and correcting potential fraud, waste, abuse, billing inaccuracies, and improper payments across all our lines of business. They also serve as a safeguard for members by ensuring healthcare dollars are used appropriately and follow applicable contractual, regulatory, and program requirements. READ MORE
Emergency Department and Outpatient Services Within 24 Hours of an Inpatient Discharge
Policy This policy is effective January 1, 2027.
Purpose This policy establishes reimbursement guidelines for emergency department (ED) and outpatient hospital services provided within 24 hours following an inpatient hospital discharge when the subsequent services are for the same or a related condition.
Policy
Health Alliance Plan by Henry Ford Health considers ED and outpatient hospital services provided by the same hospital or health system within 24 hours following an inpatient discharge to be part of the preceding inpatient stay when the subsequent services are for the same or a related condition.
When the member returns to the ED or receives outpatient hospital services within 24 hours of inpatient discharge for the same or a related condition, the subsequent facility services are considered related to the preceding inpatient admission and are not separately reimbursable.
Reimbursement for the related ED or outpatient services is considered included in the reimbursement for the preceding inpatient stay.
Reimbursement Guidelines
Health Alliance Plan will apply the following reimbursement guidelines:
The Health Alliance Plan Pledge
Health Alliance Plan continually strives to ensure that its members receive all necessary services at the appropriate time and in the appropriate setting. Utilization management decision-making is based on the appropriateness of care and service and the existence of coverage. We do not reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service. We do not offer financial incentives to encourage inappropriate underutilization of covered services.
To assist in the continual improvement of health care delivery, practitioners and physicians may obtain clinical criteria or discuss utilization management decisions. (Note: certain clinical criteria or guidelines may be
applicable only to governmental programs or only to commercial plans). READ MORE