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Identifying Members for Case Management Services

Provider Administrative Policy

Commercial Managed Care
Policy Date
August 2006
Revised/January 2011
Provider Type(s)
Hospitals   Physician  


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 case management program provides continuity of care for patients with complex and serious medical conditions. These are conditions requiring resource-intensive medical and psychosocial needs. 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 of plan benefits, coordinates needed services and fosters member independence along with  allowing members to have treatment choices .

We designed our case management program to provide continuity of care for patients with complex and serious medical conditions requiring intensive medical and psychosocial attention. Through this program, we strive to enhance the member's quality of life and promote the most cost-effective use of his or her medical benefits. We inform enrolled members and their physicians the members' plan benefits; identify possible treatment options to give members more choices, coordinate needed services and foster member independence.  

 Methods of Referral

We identify members as candidates of our case management program in a number of ways:

  • Physician referral (See PAP626)
  • Health risk assessment
  • Prior authorization requests (See PAP626)
  • Facets claim system information
  • Predictive modeling
  • Monthly and or quarterly reports
  • Member and or family request
  • Matrix referrals

A Blue Cross of Idaho case manager may contact a treating physician for information or consultation about a patient who is currently enrolled or referred to the case management program. 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 2011 Revised Title change/referral sources added
April 2010 Revised Language clarification

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