Case Management

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For enrollees meeting criteria for case management>, the case managers will develop and implement individualized case management plans. Services for enrollees with multiple or long-term care needs are carefully coordinated and often involve community support services, home health agencies, rehabilitation, therapies, durable medical equipment, and other coordination needs. For a complete description of the Case Management program and how to make a referral, see the rest of this section. If a patient is currently under case management services a blue dot will be displayed next to the member’s name in the Care Management Portal.

Case Management Referral Overview for Practitioners

What Is Case Management?

Case management is a process that promotes:

  • A patient’s access to care
  • The containment of costs
  • The enhancement of quality services and products
  • The identification of alternative care plans
  • The increase of a patient’s awareness of his disease
  • The facilitation of the enrollee's empowerment over his disease

A case manager’s role is advocacy, assessment, and coordination of care between multiple providers and the enrollee.

Who Is Appropriate for Plan-Level Case Management?

  • Patients with complex or chronic care needs
  • Patients with complex discharge planning needs
  • Patients with needs that are beyond the available clinic resources

How Can I Make a Referral to Case Management?

Please see the referral overview for clinic staff, referral form, and contact information.

For more information, call the Customer Service team at 1-800-440-1561.

What Happens When I Make a Referral?

  1. A case manager contacts the referral source within one (1) business day after receiving the referral. The conversation focuses on the reason for the referral, and a request for documentation and medical records may be made.
  2. The case manager reviews the referred enrollee's information and the documentation. The case manager attempts to contact the enrollee directly for a full assessment.
  3. Once contact with the patient is made, the case manager completes the assessment to identify if there is a potential for:
    1. Quality improvement of the patient’s health outcomes
    2. A coordinated plan of care

Case management services are offered to the enrollee at that time. If the enrollee agrees, the enrollee's case is opened in the Case Management program. If the enrollee does not agree, then Case Management services cannot be offered.

For What Reasons Would an Enrollee’s Case Not Be Opened for Plan Level Case Management?

  • Inability of the case manager to contact the enrollee after multiple (three or more) phone calls and a written request for contact.
  • Enrollee does not meet the above criteria.
  • Enrollee does not want a case manager involved in their care.

The referral source will be contacted if a case is not opened for plan level case management services.

What to Expect While an Enrollee’s Case Is Open in Plan Level Case Management

  1. Once the enrollee's case has been opened to case management, an introductory letter is sent to the patient and to the primary care provider.
  2. A collaborative care plan is completed that includes input from the providers involved in the enrollee's care, the plan level case manager, and the enrollee.
  3. A copy of this care plan is shared with the patient and the patient’s identified primary care provider.
  4. The enrollee is followed by the case manager until the treatment plan is completed and the enrollee is able to be managed at the primary care level.

Why Is a Case Closed to Plan Level Case Management?

  • The enrollee is no longer eligible with the plan.
  • The enrollee is stable and all the interventions of the case manager have been completed.

What Happens After a Case Is Closed to Plan Level Case Management?

  • A letter closing the case to plan level case management is sent to the primary care provider and the patient.
  • A satisfaction survey is mailed to the patient for evaluation of case management services.