Complex Case Management Program

Blue Shield of California Promise Health Plan has established a Complex Case Management program to provide a direct interface with our members and to work closely with their physicians to coordinate care and services for high-risk members. The goal of complex case management is to help members regain optimum health or improved functional capability, educate members regarding their chronic condition, and reinforce the primary care physician (PCP) prescribed treatment plan.

Blue Shield Promise utilizes two distinct processes to identify members for enrollment in complex case management, which include both administrative and electronic data as well as referral sources. The Plan reviews administrative data reports on at least a monthly basis, and referrals are done at the same time.

Electronic identification sources include but are not limited to the following:

• Claims data
• Encounter data
• Hospital discharge data
• Pharmacy data
• Laboratory data
• Medication Therapy Management Program

Referral identification sources include but are not limited to the following:

• Provider referrals
• Disease Management Program referrals
• Discharge planner (inpatient case manager)
• Member self-referral
• Member services referral

Referral process

Any Blue Shield Promise credentialed primary care physician or specialist may refer a member to complex case management.

Each referral will be reviewed for complex case management enrollment based on available information and a member assessment by phone. Participation in this program is free and voluntary for all eligible Blue Shield of California Promise Health Plan members. You can refer a member to this program by filling out the referral form and sending it to us:

 Population Health Management Program referral form (PDF, 57 KB)
 Fax the referral form and additional documentation or information to (323) 889-6575.

If you want additional information or would like to discuss Blue Shield Promise’s Complex Case Management Program, call Provider Services at (800) 468-9935, 6 a.m. to 6:30 p.m., Monday through Friday.

Enrollment criteria for Complex Case Management Program

Enrollment criteria for complex case management includes:

• Major organ transplant
• Major trauma
• Four or more chronic conditions
• Three or more admissions within a 12-month period
• Re-admission within 30 days with the same or similar diagnosis or condition
• Poly-pharmacy utilization consisting of more than 30 prescriptions per quarter
• Cancer diagnosis requiring multiple treatment modalities with complex care coordination across multiple disciplines

Chronic conditions:

• Diabetes
• Renal failure
• Hypertension
• Pulmonary:
  • Chronic obstructive pulmonary disease (COPD)
  • Pneumonia
  • Asthma
  • Respiratory failure
  • Pulmonary hypertension
  • Guillain-Barre Syndrome
• Cardiac:
  • Congestive heart failure
  • Cardiomyopathy
  • Coronary artery disease (CAD)
• Osteomyelitis
• Rheumatoid arthritis
• Systemic lupus erythematosus (SLE)
• Multiple sclerosis (MS)
• Parkinson's Disease
• Cirrhosis of liver / chronic liver disease
• Pressure ulcers
• Human immunodeficiency virus (HIV)
• Metastatic cancer

Primary care physician notification process

After the member is enrolled in complex case management, the primary care physician (PCP) will receive written notification of the member's enrollment, an explanation of the complex case management program, and the complex case manager's contact information.

The PCP will receive written correspondence from the complex case manager regarding clinical status updates on their member.

The complex case manager is required to call the member's PCP when there is a change in a member's condition. When applicable, they will also coordinate care and services.