The Behavioral Health Case Management Program (BHCM) aims to improve the health and quality of life for members by helping them to identify and engage appropriate services to address behavioral health concerns. Members who participate will receive individualized assistance from a Behavioral Health Case Manager in arranging for the following services:

Blue Advantage’s Complex Case Management Program identifies members with complex healthcare needs based upon their chronic condition. The goal of Complex Case Management is to help members regain optimum health and/or improved functional capability, educate members regarding their chronic condition, teach members about self-management and preventive care, reinforce the Primary Care Physician’s (PCP) prescribed treatment plan, and provide information on resources that are available to our members.

The program is a telephonic case management program and involves a comprehensive assessment of the member’s condition, determination of available benefits and resources, development and implementation of a plan of care, and coordination of services. After a member has been identified for Complex Case Management, a Registered Nurse (RN) case manager will contact the member to perform an initial assessment and develop a plan of care. The case manager works closely with the member and the member’s physician(s) to coordinate care.

Enrollment criteria for Complex Case Management includes one or more of the following diagnoses and at least one inpatient admission in the past 12 months:

Resources that we can assist you with if needed:

Referral identification sources include, but are not limited to:

General Case Management is a program designed for members who may have less complicated chronic conditions but have a risk for developing other conditions or complications and have a need for care coordination. General Case Management focuses on conditions that require monitoring and education to help members manage their health by providing support, basic education, coordination of services, and assistance locating resources. Enrollment into the General Case Management Program is not limited to any particular diagnosis. Members who do not meet criteria for Complex Case Management, but require assistance to access medical care, coordination of services, health education, and assistance locating resources, may benefit from General Case Management. This may include members with frequent hospitalizations, inappropriate emergency room use, post-hospital discharge issues, or uncontrolled, unmanaged health issues.

Members are case managed telephonically by a Registered Nurse (RN) case manager; therefore, they do not have to leave home. The case managers track members’ health status and needs over time and periodically provide them with health information. General Case Management nurses teach members about self-management and preventive care. They will also work with the member and the member’s physician(s) to coordinate the best possible care. The goal of this program is to assist members to achieve an optimal quality of life.

Resources that we can assist you with if needed:

Referral identification sources include, but are not limited to:

The purpose of Blue Advantage’s Dual Eligible Special Needs Plan (SNP) Case Management Program is to ensure that SNP beneficiaries’ healthcare needs and preferences for health services are met over time. Case Management will help to maximize the use of effective, efficient, and high-quality care that will lead to improved health outcomes. The SNP Case Management Program includes the delivery of services and benefits to members who are potentially medically complex, have multiple chronic conditions, and are disabled or facing psychosocial or socioeconomic difficulties. All Blue Advantage SNP enrollees are enrolled in SNP Case Management with an active or passive status.

The SNP Case Management Program includes a face-to-face Health Risk Assessment that is conducted by a Nurse Practitioner, a comprehensive initial assessment of the member’s condition and history by the case manager, determination of available benefits and resources, and the development and implementation of an individualized care plan. Blue Advantage’s care management plans consist of performance goals, monitoring of the member’s adherence and progress, and follow-up planning for ongoing support. Care management plans are focused on the delivery of appropriate healthcare services for members with complex, acute, and chronic care needs. The program provides an opportunity for early intervention with new and existing members so that services can be provided timely and in a satisfactory manner for the members and the members’ physicians.

The program helps to manage the member’s condition and comorbidities, assesses and identifies issues that directly and indirectly affect the member’s ability to access care, and monitors the member’s adherence to treatment plans as prescribed. In close collaboration with the member, the member’s family and healthcare providers, and the Interdisciplinary Care Team, Blue Advantage’s SNP Case Management Program supports and reinforces the individualized care plan, provides education, and coordinates available services.

Resources that we can assist you with if needed: