CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

SSBCI Chronic Condition Verification Form, LPPO D-SNP PDF. Opens in a new window

Defines member and provider submission process and clinical eligibility criteria for Special Supplemental Benefits for the Chronically Ill (SSBCI) for an Anthem/Anthem Blue Cross LPPO D-SNP plan. Lists qualifying conditions, required demonstration of severity/healthcare utilization, and submission instructions for the verification form.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicySSBCI Chronic Condition Verification Form, LPPO D-SNP PDF. Opens in a new window

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified in this update.

MultipleEligible chronic conditions listed

12 monthsUtilization lookback window

2Minimum outpatient visits for demonstration

Coverage Summary

This is a form-based verification for Special Supplemental Benefits for the Chronically Ill (SSBCI) under the Anthem Blue Cross LPPO D-SNP (Medicare/Medicaid) plan. Providers and members must complete and submit the SSBCI form per submission instructions.

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Provider Actions & Submission Requirements

Documentation Required

Provider certification on form

Provider must complete the Provider Information section, sign and date certifying that the patient meets the defined SSBCI criteria, and supply practice contact info and NPI.

Prior Authorization

Form submission requirement

Completed member/provider form must be submitted by fax to 800-833-8554, uploaded to the secure online account at www.anthem.com/ca, or mailed to P.O. Box 659403, San Antonio, TX 78265-9714.

Fax: 800-833-8554
Secure online upload: www.anthem.com/ca
Mail: P.O. Box 659403, San Antonio, TX 78265-9714

Background

This is a form-based policy to verify eligibility for Special Supplemental Benefits for the Chronically Ill (SSBCI) under the Anthem Blue Cross LPPO D-SNP Medicare/Medicaid contract. Members complete the Member Information section and take the form to their healthcare provider to complete and certify the Provider Information section.

The intent of the form is to confirm that the member has one of the eligible chronic conditions listed and to document evidence that the condition meets the CMS-aligned criteria: that it is life‑threatening or significantly limits overall health or function, has a high risk of hospitalization or other adverse outcomes, and requires intensive care coordination. The provider must sign and date the form certifying the member meets these defined SSBCI criteria.

Documented definitions

Activities of daily living (ADL)Bathing, dressing, toileting, transferring, and eating (as listed in the form).

Definitions & Thresholds

Thresholds

Lookback period for utilizationlast 12 months

Outpatient visit minimum>= 2 visits in last 12 months

Demonstration may be met by one or more of the specified utilization or functional criteria. See the form for examples of eligible chronic conditions and examples of outpatient DME (for example group 3 power/manual wheelchairs, non‑invasive ventilation, wound vacuums, BiPAP machines, mechanical in‑exsufflation devices, group 2 or group 3 mattresses).