CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

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

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Describes member and provider form and eligibility criteria for Special Supplemental Benefits for the Chronically Ill (SSBCI) for Blue Cross Blue Shield - Wisconsin members; governs how members apply and how providers certify eligibility for these supplemental 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 changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must complete and sign the Provider Information section certifying the patient meets the defined criteria and submit the completed form by fax, secure upload, or mail.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleeligible chronic conditions listed

5+severity/hospitalization pathways

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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 changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must complete and sign the Provider Information section certifying the patient meets the defined criteria and submit the completed form by fax, secure upload, or mail.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleeligible chronic conditions listed

5+severity/hospitalization pathways

Eligibility & Coverage Criteria

Eligibility criteria for SSBCI

Covered when ALL of the following are met

Eligibility preconditions

Eligible chronic conditions: Member has any one or more conditions from the enumerated list (examples include cancer; chronic heart failure; chronic kidney disease including ESRD; HIV/AIDS; chronic lung disorders such as asthma, COPD, pulmonary fibrosis; neurologic disorders including ALS, MS, Parkinson disease, epilepsy, stroke; dementia and other cognitive impairment; severe mental health conditions; autoimmune and hematologic disorders; post–organ transplant care; and other listed chronic conditions).
Full list of eligible conditions appears in chunks 4 and 5.
Demonstration of severity/need: At least one of the following must be demonstrated: 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 (including primary or specialty care); OR requirement for home health visits related to the chronic condition; OR impairment in activities of daily living or cognitive impairments related to the chronic condition; OR need for one or more outpatient durable medical equipment items (examples listed on the form).1 of the listed demonstrations
Enumerated demonstration pathways are listed in chunk 3.

Documentation and provider certification: Provider must complete the Provider Information section of the form, sign and date certifying the patient meets the defined criteria.

Provider certification and submission requirements are detailed on the form (see documentation and submission instructions).

The SSBCI form does not list any explicit exclusions for specific conditions or member groups. The form instead provides an extensive enumerated list of eligible chronic conditions from which members may qualify; absence of a condition from that list is not framed on the form as a named exclusion. See the eligible conditions enumerations for details.

The document does not provide a separate list of conditions that are not medically necessary. Determinations that a request is not medically necessary are made by comparing the member’s circumstances against the form’s eligibility criteria — i.e., whether the member has one of the listed eligible chronic conditions and meets the stated severity/need demonstrations — and by verifying the provider’s completed certification on the form. If the eligibility criteria are not met or the provider certification is absent or inadequate, the benefit would not be authorized.

Coding & Clinical Thresholds

No codes listedmixed

No codes listed

Pre-diabetes laboratory thresholds — fasting glucose and A1C ranges

Fasting blood glucose range100-125 mg/dL

Hemoglobin A1C range5.7-6.4%

Condition describedPre-diabetes listed under Diabetes mellitus

Form Submission, Certification & Provider Responsibilities

Documentation Required

Form submission (no procedure codes)

This form is a certification document only and does not include or require CPT/HCPCS procedure codes or prior authorization codes.

Do not submit procedure codes with this form.
This form is used to certify eligibility for SSBCI benefits.

Prior Authorization

Provider certification required

Providers must complete and sign the Provider Information section to certify the member meets SSBCI criteria. Incomplete or unsigned provider sections may delay or prevent benefit determination.

Complete all Provider Information fields (name, address, phone, fax, NPI).
Sign and date the certification statement.
Return the form via one of the accepted submission methods listed below.

Policy Background

Special Supplemental Benefits for the Chronically Ill (SSBCI) apply to members who have one of the enumerated chronic conditions and whose condition is life‑threatening or significantly limits overall health or function, places them at high risk of hospitalization or other adverse outcomes, and requires intensive care coordination. Intensive care coordination can be demonstrated in multiple ways on the form, including recent inpatient admissions, ER/urgent care visits, multiple outpatient visits, need for home health services, impairments in activities of daily living or cognitive function, or requirement for outpatient durable medical equipment. The form lists a broad set of eligible chronic conditions (examples include cancer, chronic heart failure, chronic kidney disease, HIV/AIDS, chronic lung disease, dementia, severe mental illness, neurologic disorders, and many others) and instructs members to have their provider complete and sign the Provider Information section and then submit the completed form by fax, secure online account upload, or mail.

Key Definitions

Intensive care coordination — definition and evidence pathways (hospitalizations, ER visits, outpatient encounters, home health, ADL/cognitive impairment, DME needs)

DefinitionIntensive care coordination: level of care management required when a member's chronic condition is life‑threatening or significantly limits health/function and has high risk of hospitalization or adverse outcomes.

Evidence pathway — inpatient admissionsOne or more inpatient admissions (inclusive of behavioral health) related to the chronic condition in the last 12 months.

Evidence pathway — ER/urgent care visitsOne or more urgent care or emergency room visits related to the chronic condition in the last 12 months.

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

Evidence pathway — home healthRequirement for home health visits related to the chronic condition.

Evidence pathway — ADL or cognitive impairment