SSBCI verification form for D-SNP members
Form to verify that Dual Eligible Special Needs Plan (D-SNP) members have at least one qualifying chronic condition to determine eligibility for Special Supplemental Benefits for the Chronically Ill (SSBCI) such as healthy food and utility assistance. Completed by the member's primary care provider, treating physician, or specialist and faxed to UnitedHealthcare.
No material clinical or coverage changes in this revision.
Eligibility Criteria for SSBCI
Form Submission & Provider Responsibilities
Submit completed SSBCI verification form (signed, dated, faxed)
Complete, sign, and fax the SSBCI verification form to UnitedHealthcare to confirm the member has at least one listed chronic condition (or indicate 'None'). The form must be completed by the member's primary care provider, treating physician, or specialist and include provider signature, date, phone, and member name, Medicare ID, and date of birth. Fax the completed form to 877-389-1802.
- Form must be completed by primary care provider, treating physician, or specialist (Use and disclosure authorization).
- Certify which qualifying chronic condition(s) the applicant has, or circle 'None; Patient not seen / No chronic conditions'.
- Include provider signature, date, phone number, member name, Medicare ID (MBI/HICN), and date of birth.
- Fax the completed form to UnitedHealthcare at 877-389-1802.
Key Definitions
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.