CurrentBlue Cross Blue Shield - NevadaPolicy N/A

Special Supplemental Benefits for the Chronically Ill (SSBCI)

This document describes eligibility criteria and the application process for Special Supplemental Benefits for the Chronically Ill (SSBCI) for Anthem/Blue Cross Blue Shield members, and directs members and providers on how to complete and submit the SSBCI form.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicySpecial Supplemental Benefits for the Chronically Ill (SSBCI)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed SSBCI form (member and provider sections) via fax, secure upload, or mail to initiate benefit determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

one-page formapplication form with member and provider sections

6+ indicatorsways to demonstrate need

70+eligible chronic conditions

fax/upload/mailsubmission options

Coverage Criteria — SSBCI Eligibility

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicySpecial Supplemental Benefits for the Chronically Ill (SSBCI)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed SSBCI form (member and provider sections) via fax, secure upload, or mail to initiate benefit determination.

SourceLink

On This Page

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Overall eligibility

Demonstration of need: One or more of the following within the last 12 months: one or more inpatient admissions related to the chronic condition; OR one or more urgent care or emergency room visits related to the chronic condition; OR two or more outpatient visits related to the chronic condition (including primary or specialty care); OR the patient requires home health visits related to the chronic condition; OR the patient has impairment in activities of daily living or cognitive impairments related to the chronic condition (bathing, dressing, toileting, transferring, eating); OR the patient with a chronic condition requires one or more outpatient durable medical equipment (DME) items (including but not limited to group 3 power/manual wheelchair, non-invasive ventilation, wound vacuums, BiPAP machines, mechanical in-exsufflation devices, group 2 or group 3 mattresses).
Any single listed demonstration fulfills this node.

Eligible chronic conditions: Member has one or more of the eligible chronic conditions as listed (examples include but are not limited to: chronic alcohol/substance use disorders; autoimmune disorders (polyarteritis nodosa, polymyalgia rheumatica, polymyositis, dermatomyositis, rheumatoid arthritis, systemic lupus erythematosus, psoriatic arthritis, scleroderma); cancer; cardiovascular disorders (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, valvular heart disease, chronic heart failure); dementia; diabetes mellitus (including pre-diabetes with fasting blood glucose 100-125 mg/dL or Hgb A1C 5.7-6.4%); overweight/obesity/metabolic syndrome; chronic gastrointestinal disease (chronic liver disease, NAFLD, hepatitis B, hepatitis C, pancreatitis, IBS, IBD); chronic kidney disease (with or without dialysis/ESRD); severe hematologic disorders (aplastic anemia, hemophilia, immune thrombocytopenic purpura, myelodysplastic syndrome, sickle-cell disease excluding trait, chronic venous thromboembolic disorder); HIV/AIDS; chronic lung disorders (asthma, chronic bronchitis, cystic fibrosis, emphysema, pulmonary fibrosis, pulmonary hypertension, COPD); chronic and disabling mental health conditions (bipolar disorder, major depressive disorder, paranoid disorder, schizophrenia, schizoaffective disorder, PTSD, eating disorders, anxiety disorders); neurologic disorders (ALS, cerebral palsy, epilepsy, extensive paralysis, Huntington's disease, multiple sclerosis, Parkinson's disease, polyneuropathy, fibromyalgia, chronic fatigue syndrome, spinal cord injuries, spinal stenosis, stroke-related neurologic deficit, traumatic brain injury); post-organ transplantation care; immunodeficiency/immunosuppressive disorders; conditions causing cognitive impairment (Alzheimer's disease, intellectual and developmental disabilities, traumatic brain injuries, disabling mental illness with cognitive impairment, mild cognitive impairment); conditions causing similar functional challenges (paralysis, limb loss, arthritis, chronic vision/hearing/taste/touch/smell impairment); conditions requiring continued therapy services; other chronic conditions such as hypertension, osteoporosis, chronic back pain.

See source eligible conditions lists for complete details.

Form Submission, Certification, and Signature Requirements

Prior Authorization

Form submission to request SSBCI

Submit the completed SSBCI form (both Member and Provider sections) to initiate a benefit determination. You may fax the form to 800-833-8554, upload it securely via the member's online account at www.anthem.com, or mail it to P.O. Box 659403, San Antonio, TX 78265-9714.

Fax: 800-833-8554
Secure upload: www.anthem.com (member online account)
Mail: P.O. Box 659403, San Antonio, TX 78265-9714

Documentation Required

Provider certification

By signing the Provider Information section, the provider certifies the patient meets the defined SSBCI criteria. The Provider Information section must include provider first and last name, address, phone, fax, and NPI. The provider must complete and sign the signature and date fields to attest the patient meets the SSBCI criteria.

Provider must complete all Provider Information fields (name, address, phone, fax, NPI)
Provider must sign and date the certification statement

Denial Risk

Submission and signature requirements

Incomplete, missing, or unsigned Provider Information, or failure to submit the completed form via fax, secure upload, or mail, may result in the form not being processed. Ensure the Provider Information section is fully completed and signed before submission.

Unsigned or incomplete provider section may result in non-processing
Accepted submission methods: fax, secure upload, or mail

Note

Provider action: clinical documentation

Providers: complete the Member Information section with the member prior to submission and ensure clinical support for eligibility is documented per CMS SSBCI qualifying conditions (e.g., recent admissions, ED/urgent care visits, outpatient visits, home health visits, impairments in activities of daily living, or need for DME).

Document one or more qualifying events or needs related to the chronic condition per CMS guidelines

Program Background

The Special Supplemental Benefits for the Chronically Ill (SSBCI) are intended for members with chronic health conditions that are life‑threatening or significantly limit overall health or function, carry a high risk of hospitalization or other adverse outcomes, and require intensive care coordination. Eligibility is determined by documented clinical encounters or functional needs such as recent inpatient admissions, emergency or urgent care visits, recurrent outpatient visits, need for home health, impairment in activities of daily living related to the condition, or requirement for outpatient durable medical equipment (examples provided in the form).

Demonstration of Need and DME Examples

Demonstration of need (clinical indicators)

Inpatient admissionsOne or more inpatient admissions related to the chronic condition in the last 12 months

Urgent care / ED visitsOne or more urgent care or emergency room visits related to the chronic condition in the last 12 months

Outpatient visitsTwo or more outpatient visits related to the chronic condition (including primary or specialty care) in the last 12 months

Home health requirementPatient requires home health visits related to the chronic condition

ADL impairmentImpairment in activities of daily living or cognitive impairments related to the chronic condition (bathing, dressing, toileting, transferring, eating)

Outpatient DME needPatient requires one or more outpatient durable medical equipment items (examples listed)

Durable medical equipment (DME) examples

Group 3 wheelchairsGroup 3 power or manual wheelchair

Non-invasive ventilationNon-invasive ventilation (NIV), including BiPAP machines

Wound care devicesWound vacuums

Mechanical insufflation-exsufflationMechanical in-exsufflation devices

Therapeutic mattressesGroup 2 or group 3 mattresses

OpenPayer

Special Supplemental Benefits for the Chronically Ill (SSBCI)

Coverage Criteria — SSBCI Eligibility

Laboratory and Diagnostic Thresholds

Form Submission, Certification, and Signature Requirements

Program Background

Demonstration of Need and DME Examples