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Identifying Members for Case Management Services

Provider Administrative Policy

Care Management
Policy Date
May 2008
Revised/January 2012


Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.


Identifying Members for Case Management Services

Blue Cross of Idaho`s Medicare Advantage case management program provides continuity of care for patients with complex and serious medical conditions. These are conditions requiring resource-intensive medical and psychosocial care. Working to enhance the member`s quality of life while promoting the most cost-effective use of medical benefits, the program  educates members and providers on plan benefits, coordinates needed services and fosters member independence along with allowing treatment choices.

Members receive case management referrals in a number of ways:

  • Physician referrals
  • Health risk assessments
  • Prior authorization requests
  • Facets claim system information
  • Predictive modeling
  •  Monthly and or quarterly reports
  • Member and or family request
  • Matrix Health referrals
  • Eligibility as a True Blue HMO special needs plan member

A Blue Cross of Idaho case manager may contact a provider for information or consultation about a patient currently in the case management program. Providers may refer True Blue HMO or Secure Blue PPO members who they believe would benefit from case management (see MA PAP102). Prompt notification by providers of high-risk members will allow those members to receive optimal care within the scope of their benefits.

Policy History

Date Action Reason
January 2012 Revised Removed Flexi Blue language
February 2011 Revised Title change/referral sources added
April 2010 Revised Language clarification
July 2008 Revised Risk categories added/removed
May 2008 Revised Language clarification

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