CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Special Supplemental Benefits for the Chronically Ill (SSBCI) - Coverage Criteria

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Form and criteria for members to request Special Supplemental Benefits for the Chronically Ill (SSBCI); describes member/provider submission steps and qualifying clinical conditions for eligibility. Affects Medicare beneficiaries covered by Blue Cross Blue Shield plans who seek SSBCI benefits.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicySpecial Supplemental Benefits for the Chronically Ill (SSBCI) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed SSBCI form by fax to 800-833-8554, upload to your secure online account at www.anthem.com, or mail to P.O. Box 659403, San Antonio, TX 78265-9714.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=1inpatient admissions in prior 12 months can demonstrate eligibility

>=1

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CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Special Supplemental Benefits for the Chronically Ill (SSBCI) - Coverage Criteria

Customize your policy alerts

Sign up for all Blue Cross Blue Shield - Wisconsin policy alerts

Know when Blue Cross Blue Shield - Wisconsin releases new policies or updates existing guidance.

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Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicySpecial Supplemental Benefits for the Chronically Ill (SSBCI) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed SSBCI form by fax to 800-833-8554, upload to your secure online account at www.anthem.com, or mail to P.O. Box 659403, San Antonio, TX 78265-9714.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=1inpatient admissions in prior 12 months can demonstrate eligibility

>=1

Coverage Criteria for SSBCI

SSBCI eligibility criteria

Covered when ALL of the following are met

Overall eligibility

Qualifying condition: Member has one of the enumerated chronic conditions (see eligible conditions lists).
See chunks 4-5 for full list.
Demonstration of severity/need: One or more inpatient admissions related to the chronic condition in the last 12 months OR one or more urgent care or emergency room visits related to the chronic condition in the last 12 months OR two or more outpatient visits related to the chronic condition in the last 12 months OR requires home health visits related to the chronic condition OR has an impairment in activities of daily living related to the chronic condition (bathing, dressing, toileting, transferring, eating) or cognitive impairments OR has a need for one or more outpatient durable medical equipment (DME) items related to the chronic condition (including but not limited to: group 3 power/manual wheelchair, non-invasive ventilation, wound vacuums, BiPAP machines, mechanical insufflation-exsufflation devices, group 2 or group 3 mattresses).See child text
Demonstration criteria are per CMS guidelines in the form (chunk 3).

The form does not list explicit general exclusions; however, within the enumerated eligible conditions the policy explicitly states that sickle-cell disease excludes sickle-cell trait. Use the eligible conditions lists to determine qualifying diagnoses and note this specific exclusion when assessing members with sickle-cell trait.

No additional not-medically-necessary statements or explicit exclusions beyond the condition lists are provided on the form.

Coding and Evidence Thresholds

No billing codes provided on formmixed

No codes listed

Visit-count thresholds for demonstrating need

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

Urgent care / ER visit thresholdOne or more urgent care or emergency room visits related to the chronic condition in the last 12 months

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

Form Submission and Provider Responsibilities

Prior Authorization

Submit completed SSBCI form via fax, secure upload, or mail

Completed SSBCI form must be submitted via one of the specified channels: fax to 800-833-8554, uploaded to the member's secure online account at www.anthem.com, or mailed to P.O. Box 659403, San Antonio, TX 78265-9714.

Step Therapy

Provider certification by signature

Provider signature on the form certifies that the referenced patient meets the defined SSBCI criteria as outlined on the form; no additional step-therapy requirements are specified on the form.

Documentation Required

Complete Provider Information, include identifiers, and sign attestation

Background

Special Supplemental Benefits for the Chronically Ill (SSBCI) eligibility requires a qualifying chronic condition that is life‑threatening or significantly limits health or function, carries a high risk of hospitalization or adverse outcomes, and requires intensive care coordination. Demonstration of need may be shown by utilization or clinical impairment such as >=1 inpatient admission in the prior 12 months, >=1 urgent care/ER visit in the prior 12 months, >=2 outpatient visits in the prior 12 months, requirement for home health related to the condition, impairments in activities of daily living or cognitive impairment related to the condition, or need for one or more outpatient DME items.

Definitions and Evidence of Need

Evidence of need — Qualifying demonstration criteria

Demonstration via inpatient/ED/urgent careOne or more inpatient admissions OR one or more urgent care or emergency room visits related to the chronic condition in the last 12 months

Demonstration via outpatient visitsTwo or more outpatient visits related to the chronic condition in the last 12 months (includes primary care or specialty visits)

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

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

Outpatient DME needNeed for one or more durable medical equipment items in the outpatient setting (examples include group 3 power/manual wheelchair, non-invasive ventilation, wound vacuums, BiPAP, mechanical insufflation-exsufflation devices, group 2 or 3 mattresses)