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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyEmpire Bluecross SSBCI Provider Attestation Covera…
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    CurrentEmpire BluecrossPolicy N/A

    Provider Confirmation: Special Supplemental Benefits for the Chronically Ill (SSBCI)

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    This form documents provider confirmation that a Medicare Advantage member meets CMS SSBCI eligibility and clinical criteria for one or more chronic-condition supplemental benefits; it is completed and signed by the treating provider and submitted to the payer. Affects providers caring for Medicare Advantage members in the listed states seeking SSBCI benefits.

    Policy Summary
    PayerEmpire Bluecross
    PolicyProvider Confirmation: Special Supplemental Benefits for the Chronically Ill (SSBCI)
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionComplete and sign the attestation form and fax it to 877-660-8362 to document member eligibility for SSBCI benefits.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ~60+eligible chronic conditions listed
    12 months

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    lookback period
    faxsubmission method
    requiredsignature required

    Coverage Criteria for SSBCI Benefits

    SSBCI eligibility and qualifying conditions

    Covered when ALL of the following CMS-aligned conditions are satisfied and documented by provider attestation:

    Core eligibility requirements: Member has one of the eligible chronic conditions listed AND the condition is life-threatening or significantly limits overall health or function AND the condition places the member at high risk of hospitalization or other adverse health outcomes AND the condition requires intensive care coordination.

    Supported by provider attestation on form.

    Demonstration of meeting conditions: At least one of the following demonstrations is present: one or more inpatient admissions related to the chronic condition in the last 12 months; one or more urgent care or emergency room visits related to the chronic condition in the last 12 months; two or more outpatient visits related to the chronic condition in the last 12 months; requirement for home health visits related to the chronic condition; impairment in activities of daily living or cognitive impairments related to the chronic condition; need for one or more outpatient durable medical equipment (examples include group 3 power/manual wheelchair, noninvasive ventilation, wound vacuums, BiPAP machines, mechanical insufflation-exsufflation devices, group 2 or 3 mattresses).12 months for utilization-based items

    Each item alone is sufficient; document which demonstration applies on the attestation form.

    The form enumerates the eligible chronic conditions that may qualify a Medicare Advantage member for SSBCI benefits; it does not list any explicit exclusions. Eligible diagnoses include a broad range of chronic disease categories and specific conditions such as substance use disorders, autoimmune disorders (for example, rheumatoid arthritis, systemic lupus erythematosus), cancer, cardiovascular disorders (for example, coronary artery disease, chronic heart failure), diabetes, chronic gastrointestinal and liver disease, chronic kidney disease (with and without dialysis), severe hematologic disorders, chronic lung disorders (for example, COPD, pulmonary fibrosis), chronic and disabling mental health conditions (for example, schizophrenia, bipolar disorder), neurologic disorders (for example, ALS, multiple sclerosis, stroke), post-organ transplant care, immunodeficiency disorders, and other conditions that produce similar functional challenges (for example, spinal cord injuries, limb loss, chronic back pain, vision or hearing impairment).

    This document functions as a provider attestation form used to confirm that a member meets CMS SSBCI eligibility requirements; it is an evidence‑collection and signature tool submitted to the payer and does not itself define which services are or are not medically necessary.

    Coding and Lookback Period

    Lookback period for utilization criteria
    Lookback period12 months
    Scope of lookbackApplies to inpatient admissions, urgent care/ED visits, and outpatient visits referenced in utilization criteria
    Calculation windowCount events occurring within the 12 months prior to attestation date

    Provider Submission, Attestation, and Signature Requirements

    Prior Authorization

    Provider attestation submission via fax

    Submit the completed, signed Provider Confirmation attestation form to the payer by fax to 877-660-8362 to confirm the member’s eligibility for SSBCI benefits per CMS guidelines.

    • Form documents qualifying chronic condition(s) and supporting clinical demonstrations (see form).
    • Fax transmission is the required submission method.
    Note

    Provider actions — attest and document qualifying evidence

    Complete and submit the attestation form exactly as instructed; this form is the provider’s confirmation that the member meets CMS SSBCI eligibility and clinical criteria and must be retained as documentation of eligibility.

    • Attestation must document which eligible chronic condition(s) apply and how the condition meets the CMS-aligned criteria.
    • Use the form to show demonstrations (inpatient/ED visits, outpatient visits, home health, ADL/cognitive impairment, or DME needs).

    Background and Policy Context

    Per CMS SSBCI guidance captured on the form, members must have a qualifying chronic condition that is life‑threatening or significantly limits overall health or function, places the member at high risk of hospitalization or other adverse outcomes, and requires intensive care coordination. The form also specifies ways to demonstrate these criteria within a 12‑month lookback period, such as recent inpatient admission, urgent care/ED visits, multiple outpatient visits related to the condition, requirement for home health visits, measurable impairment in activities of daily living or cognition, or need for specified outpatient durable medical equipment.

    Definitions and Demonstration of Eligibility

    Demonstrations of meeting SSBCI condition (examples)
    Inpatient admissionsOne or more inpatient admissions (including behavioral health) related to the chronic condition within the 12-month lookback period
    Urgent care or emergency visitsOne or more urgent care or emergency room visits related to the chronic condition within the 12-month lookback period
    Outpatient visitsTwo or more outpatient visits (primary or specialty care) related to the chronic condition within the 12-month lookback period
    Home health requirementRequirement for home health visits related to the chronic condition within the lookback period qualifies as demonstration
    Functional or equipment needsImpairment in activities of daily living or need for outpatient DME (examples listed) also qualify within the lookback period
    Policy Summary
    PayerEmpire Bluecross
    PolicyProvider Confirmation: Special Supplemental Benefits for the Chronically Ill (SSBCI)
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionComplete and sign the attestation form and fax it to 877-660-8362 to document member eligibility for SSBCI benefits.
    SourceLink
    On This Page
    Coverage Criteria for SSBCI BenefitsCoding and Lookback PeriodProvider Submission, Attestation, and Signature RequirementsBackground and Policy ContextDefinitions and Demonstration of Eligibility
    Documentation Required

    Complete required form fields and include provider NPI/signature

    Complete all required member and provider fields on the form, indicate whether the patient meets the defined criteria, and sign and date the form; include provider NPI and fax the completed form to the specified number.

    • Member section: name, date of birth, Medicare beneficiary ID, member ID.
    • Provider section: name, address, phone, NPI; attest whether patient meets criteria; signature and date required.
    Denial Risk

    Risk: incomplete/signature or incorrect submission may cause denial or delay

    Failure to complete and sign the provider information section or to fax the form to 877-660-8362 may result in lack of documented confirmation and potential denial or processing delays for SSBCI benefit access.

    • Ensure signature and date are present in the provider section before faxing.
    • Use the correct fax number (877-660-8362) to avoid processing delays or denials.