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 SSBCI benefits from Blue Cross Blue Shield - Wisconsin; instructs members and providers on how to apply and documents eligible chronic conditions and qualifying utilization/function criteria.

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, secure online account upload, or mail to request the benefit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

fax/web/mailsubmission methods provided

12lookback period (months)

multiple

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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.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

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, secure online account upload, or mail to request the benefit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

fax/web/mailsubmission methods provided

12lookback period (months)

multiple

SSBCI Coverage Criteria

SSBCI eligibility criteria

Covered when ALL of the following conditions are met:

Member has eligible chronic condition: Member has one of the listed eligible chronic conditions (see eligible conditions list).

Eligible conditions list spans multiple categories including cardiovascular, pulmonary, neurologic, metabolic, mental health, autoimmune, cancer, renal, and others.

Condition meets severity/function thresholds: Condition is life-threatening or significantly limits overall health or function, has a high risk of hospitalization or other adverse health outcomes, and requires intensive care coordination.

Demonstrated need via utilization or impairment: One or more of the specified indicators within the last 12 months must be demonstrated: one or more inpatient admissions related to the chronic condition, one or more urgent care or emergency room visits related to the chronic condition, two or more outpatient visits related to the chronic condition, need for home health visits related to the chronic condition, impairment in activities of daily living or cognitive impairment related to the chronic condition, or need for one or more outpatient DME (including but not limited to group 3 power/manual wheelchair, non-invasive ventilation, wound vacuums, BiPAP, mechanical in-exsufflation devices, group 2 or group 3 mattresses).1 of listed indicators within 12 months

DME examples listed are not exhaustive; documentation must link the DME to the chronic condition.

The SSBCI form does not list explicit exclusions; instead it provides an extensive enumeration of eligible chronic conditions across multiple categories (cardiovascular, pulmonary, neurologic, metabolic, mental health, autoimmune, cancer, renal, and others). The policy treats the listed conditions and other conditions that cause similar functional challenges as potentially eligible when the member also meets the severity and utilization/functional criteria described below.

Providers should therefore use the eligible conditions list as inclusive guidance: conditions explicitly named (for example, diabetes, chronic kidney disease, COPD, multiple sclerosis, dementia, cancer, and many others) and conditions described as causing similar functional limitations may qualify if the additional eligibility requirements are met.

The benefit is not covered if the member cannot demonstrate one or more of the qualifying utilization or functional impairment indicators related to the chronic condition within the prior 12 months. Qualifying indicators include inpatient admission, urgent care/ED visit, two or more outpatient visits for the condition, need for home health, impairment in activities of daily living or cognitive impairment, or need for specified outpatient DME.

Laboratory & Diagnostic Thresholds

Pre-diabetes laboratory thresholds

Fasting blood glucose100-125 mg/dl

Hemoglobin A1C (Hgb A1C)5.7-6.4%

Condition contextListed as criteria for pre-diabetes under 'Diabetes mellitus' eligible conditions

Form Submission & Documentation Requirements

Note

Form submission requirement

Submit the completed SSBCI form by one of the following channels: fax to 800-833-8554; upload to the member's secure online account at www.anthem.com; or mail to P.O. Box 659403, San Antonio, TX 78265-9714.

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

Documentation Required

Required form and clinical documentation

Providers must complete the Provider Information section and sign to certify the patient meets the defined SSBCI criteria. The provider section must include the provider's name, practice address, phone and fax, NPI, signature and date.

Provider first and last name
Street address, city, state, ZIP
Phone number and fax number

Qualifying Utilization & Impairment Indicators

Qualifying utilization/impairment indicators

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

Urgent care or 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 (primary or specialty) visits related to the chronic condition in the last 12 months

Home health needRequirement for home health visits related to the chronic condition within the last 12 months

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 specified outpatient durable medical equipment (e.g., group 3 power/manual wheelchair, NIV, wound vacuums, BiPAP, mechanical in-exsufflation devices, group 2/3 mattresses)

Policy Background

SSBCI is intended for members with chronic 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 requires demonstration of recent healthcare utilization or functional impairment related to the chronic condition (see qualifying indicators) within the last 12 months.