Complex Case Management


has established a Complex Case Management Program to provide a direct interface with our members and work closely with their physician to coordinate care and services to 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 PCP prescribed treatment plan.

utilizes two distinct processes to identify members for enrollment in Complex Case Management that includes both administrative/electronic data and/or referral sources. Administrative data reports are reviewed on a minimum of a monthly basis, referrals are concurrent.

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 credentialed PCP/Specialist may refer a member to Complex Case Management.
Each referral will be reviewed for enrollment in Complex Case Management based on available information and telephonic member assessment. Participation in this program is free and voluntary for all eligible members. You can refer a member to this program by filling out this form.

If you want additional information or would like to discuss the Complex Case Management Program you can call (800) 468-9935 or you can fax the Referral Form and/or additional documentation/information to (323) 889-6575.

Enrollment Criteria for Complex Case Management

  • Major Organ Transplant
  • Major Trauma
  • 4 or More Chronic Conditions
  • 3 or more Admits within a 12 Month Period
  • Readmission with Thirty (30) Days with the Same/Similar Diagnosis/Condition
  • Polypharmacy Utilization Consisting of >30 Prescriptions per Quarter
  • Diagnosis of cancer requiring multiple modalities of treatment with complex coordination of care across multiple disciplines

Chronic Conditions

  • Diabetes
  • Renal Failure
  • Hypertension
  • Pulmonary:
    • COPD, Pneumonia, Asthma, Respiratory Failure, Pulmonary HTN, Guillain-Barre Syndrome
  • Cardiac:
    • CHF, Cardiomyopathy, CAD
  • Osteomyelitis
  • Rheumatoid Arthritis
  • SLE
  • Multiple Sclerosis
  • Parkinson's Disease
  • Cirrhosis of Liver / Chronic Liver Disease
  • Pressure Ulcers
  • HIV
  • Metastatic Cancer

Primary Care Provider Notification Process

After the member is enrolled in Complex Case Management the PCP is notified in writing of the member's enrollment and an explanation of the CCM Program and Complex Case Manager contact information.

The PCP will periodically receive written correspondence from the Complex Case Manager for a clinical status update on their member.

The Complex Case Manager is required to telephonically contact the member's PCP when there is a change in member condition and to coordinate care/services when applicable.

Blue Shield Promise Programs