CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

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

Defines eligibility criteria, qualifying chronic conditions, and the form submission process for members seeking Special Supplemental Benefits for the Chronically Ill; intended for providers and Medicare-enrolled members to determine and document eligibility for SSBCI.

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 a completed Member and Provider form (including provider signature) by fax, secure online upload, or mail to initiate benefit evaluation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3submission methods (fax, online upload, mail)

1required provider certification signature on form

>=1evidence items required to demonstrate need

50+listed eligible chronic conditions

Coverage and Eligibility Criteria

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SSBCI Eligibility Criteria

Covered when ALL of the following are met:

Overall eligibility

Demonstration of condition severity or service need: One or more of the following in 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; OR requirement for home health visits related to the chronic condition; OR impairment in activities of daily living or cognitive impairment related to the chronic condition; OR need for one or more specified outpatient durable medical equipment (DME) items.see node text
Specified outpatient DME examples include group 3 power/manual wheelchairs, non-invasive ventilation (NIV), wound vacuums, BiPAP machines, mechanical in-exsufflation devices, group 2 or group 3 mattresses.

No specific exclusions are listed on the SSBCI form. Eligibility is limited by the requirement that the member must have one of the listed eligible chronic conditions and must also meet at least one of the demonstrated severity/service‑need criteria within the last 12 months (for example: inpatient admission, urgent care/ED visit, two or more outpatient visits, home health visits, impairment in activities of daily living or cognitive impairment, or need for specified outpatient DME).

The policy does not enumerate discrete "not medically necessary" scenarios on the form; however, benefit eligibility is contingent on submission of the completed member and provider sections with the provider certification/signature and documentation that demonstrates the qualifying criteria. Failure to provide a completed form or to document one or more of the required utilization/functional/DME criteria may result in denial of SSBCI benefit eligibility.

Provider Submission, Documentation, and Denial Triggers

Prior Authorization

Form submission requirement

Submit the completed SSBCI form to initiate the benefit request. Completed forms may be submitted by fax to 800-833-8554, uploaded to the member's secure online account at www.anthem.com/ca, or mailed to P.O. Box 659403, San Antonio, TX 78265-9714.

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

Documentation Required

Required provider attestation

The provider must sign and date the Provider Information section certifying the member meets the defined SSBCI criteria and include complete provider contact details. Missing provider certification/signature or omitted provider information may lead to denial.

Required provider fields: first and last name, street address, city, state, ZIP, phone number, fax number, NPI
Provider attestation: handwritten or electronic signature and date certifying the patient meets SSBCI criteria

Denial Risk

Triggers for denial

Denial triggers include failure to include the provider's certification/signature, missing or incomplete provider contact information, or insufficient documentation demonstrating the member meets qualifying criteria (e.g., evidence of inpatient/ER/urgent care visits, outpatient visit frequency, need for home health, impairments in activities of daily living, cognitive impairment, or documented need for DME).

Missing provider certification/signature or date
Incomplete or missing provider identifying information (NPI, address, phone)
Lack of supporting documentation showing the member meets qualifying utilization, functional impairment, or DME needs as described in the form

Program Background

The purpose of SSBCI is to identify Medicare beneficiaries with eligible 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. The program targets members who can demonstrate recent condition severity or service need—such as recent inpatient admission, urgent care/ED visit, multiple outpatient visits, home health, functional impairment in activities of daily living or cognitive function, or need for specified outpatient durable medical equipment—and requires submission of the completed form to initiate evaluation.

Definitions and Examples

Qualifying demonstration of need

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

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

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

Home healthRequirement for home health visits related to the chronic condition

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

Specified DME examples

Group 3 wheelchairsGroup 3 power/manual wheelchairs (outpatient DME example)

Non-invasive ventilationNon-invasive ventilation (NIV)

Wound vacuumsWound vacuums

BiPAP machinesBiPAP machines

Mechanical in-exsufflationMechanical in-exsufflation devices