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Identifying Members Who Require Case Management

Provider Administrative Policy

Commercial Managed Care
Policy Date
December 2002
Revised/January 2011
Provider Type(s)
All Providers  


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 Who Require Case Management

  • High-risk conditions or situations that may require case management aggregate claims of greater than $50,000 per year.
  • AIDS or HIV related conditions.
  • Burns greater than or equal to 20 percent of body area.
  • Cancer with intensive treatment and/or special needs.
  • Cerebrovascular accident with sequelae with continued functional impairment.
  • Change primary care physician (PCP) three or more times in one year if for other reasons than network changes.
  • Chronic renal failure/ESRD.
  • COPD with two or more hospital admissions within last year.
  • Diabetes mellitus with complications such as labile blood glucose, open wounds, nephropathy, retinopathy or neuropathy that puts patient as risk for further complications or lifestyle changes.
  • End-of-life issues.
  • Greater than one hospitalization within the past three months.
  • Greater than one emergency room visit in the past three months.
  • High-risk pregnancy.
  • Multiple chronic and acute conditions identified through reports and referrals.
  • Multi-system health problems (three or more co-morbidities).
  • Neuromuscular disorders (i.e. multiple sclerosis, muscular dystrophy, ALS, myasthenia gravis, cerebral palsy) with rapidly deteriorating status or exacerbation that put patient at risk for lifestyle changes.
  • Organ transplants.
  • Prolonged inpatient stay.
  • Repeated acute hospital admissions (three or more admissions in last year).
  • Trauma.
  • Wounds at level three or four, or several lesser wounds; wound orders include sharp or chemical debridement; an in-patient wound program has been ordered by the treating wound specialist.

Policy History

Date Action Reason
January 2011 Revised Title change/criteria updated
April 2010 Revised Language clarification
May 2008 Revised Title change

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