CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Special Supplemental Benefits for the Chronically Ill (SSBCI) attestation and eligibility form

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This form and policy govern eligibility and enrollment for Special Supplemental Benefits for the Chronically Ill (SSBCI) for Anthem/BCBS members and instruct members and providers on completing and submitting the SSBCI attestation form.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicySpecial Supplemental Benefits for the Chronically Ill (SSBCI) attestation and eligibility form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProvider must complete and sign the Provider Information section certifying the patient meets defined criteria and document evidence of qualifying chronic condition and utilization or functional/DME needs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page / form

6+qualifying utilization examples

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CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Special Supplemental Benefits for the Chronically Ill (SSBCI) attestation and eligibility form

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

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Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicySpecial Supplemental Benefits for the Chronically Ill (SSBCI) attestation and eligibility form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page / form

6+qualifying utilization examples

Coverage Criteria

SSBCI eligibility criteria

Covered when ALL of the following are met

Eligibility prerequisites: Member has one of the eligible chronic conditions listed AND the condition is life-threatening or significantly limits overall health/function, has a high risk of hospitalization or other adverse health outcomes, and requires intensive care coordination.

Eligible conditions listed in chunks 4 and 5; general requirement language from chunk 3

Demonstration of need/utilization: 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 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 (bathing, dressing, toileting, transferring, eating, or cognitive impairment) OR need for one or more outpatient durable medical equipment (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).

Specific utilization and DME examples from chunk 3

The document does not provide a separate list of exclusions. Instead, eligibility is defined by meeting the stated qualifying conditions and demonstration criteria; any condition that does not meet those listed chronic-condition requirements or the required evidence of need/utilization would be outside coverage under this attestation-based policy. This form functions to confirm eligibility rather than to enumerate explicit exclusions.

This form is an attestation of eligibility: providers must complete and sign the Provider Information section certifying the patient meets the defined criteria. There are no "not medically necessary" statements on the form; instead, eligibility is established by the provider attestation plus documented evidence (for example, the utilization or functional/DME needs listed on the form). Submit the completed form by fax, secure upload, or mail to the addresses provided on the form.

Coding and Clinical Thresholds

Pre-diabetes lab thresholds — fasting blood glucose and Hgb A1C ranges

Fasting blood glucose100-125 mg/dl

Hemoglobin A1C (Hgb A1C)5.7-6.4%

Clinical contextThese values identify pre-diabetes as listed under Diabetes mellitus in the eligible conditions.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Not Specified (Attestation Form)

No prior authorization (PA) codes are listed on this form. Providers should note that prior authorization requirements are not specified here — this document functions as an attestation form for Special Supplemental Benefits for the Chronically Ill (SSBCI). If PA is required for any service or equipment identified during care, obtain prior authorization through the payer's standard PA process before billing.

This form itself does not authorize services or DME — it documents eligibility for SSBCI benefits.
If a specific treatment or device requires prior authorization, follow Blue Cross Blue Shield - Wisconsin prior authorization procedures.

Documentation Required

Provider Attestation and Required Documentation

Providers: complete the Provider Information section fully, sign and date the attestation, and document supporting clinical evidence demonstrating the member meets qualifying criteria (see qualifying conditions and evidence list). Incomplete or unsigned provider attestation may prevent the member from being enrolled in SSBCI benefits.

Definitions and Utilization Criteria

Qualifying utilization and needs — examples of utilization, home health, ADL, and DME

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

Home healthRequirement for home health visits related to the chronic condition

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

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

Background

The purpose of the Special Supplemental Benefits for the Chronically Ill (SSBCI) is to identify and enroll members with chronic conditions that are life-threatening or significantly limit overall health or function, carry a high risk of hospitalization or other adverse health outcomes, and require intensive care coordination. Eligibility must be demonstrated by recent utilization or needs such as one or more inpatient admissions, one or more urgent care or ED visits, two or more outpatient visits, requirement for home health, impairment in activities of daily living or cognitive function, or need for outpatient DME. The completed member and provider sections must be submitted by fax, secure upload, or mail as instructed on the form.