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    v1.0.31
    OpenPayerPolicy UpdatesBlue Shield of CaliforniaBlue Shield CA Case Management Update | OpenPayer
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    CurrentBlue Shield of California Promise Health PlanPolicy 10.02.69

    UM Referral to Complex Case Management

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    This policy governs how Blue Shield of California Promise Health Plan identifies Medi-Cal members with complex care needs and refers them to Complex Case Management, including case management, care coordination, and transitions for children, skilled nursing facility members, CCS-eligible members, and members with developmental disabilities.

    Policy Summary
    PayerBlue Shield of California Promise Health Plan
    PolicyUM Referral to Complex Case Management
    Policy CodePolicy N/A
    Change TypeAdministrative and reference update
    Effective Date5/19
    Next Review DateN/A
    Key ActionRefer members to the Case Management Department when a complex care need is identified through the listed indicators or chronic conditions.
    SourceLink
    POLICY UPDATE CHANGES

    The revision history documents annual review and updates to regulatory references, formatting, grammar, policy numbering, and the approver.

    Under 21Members receiving case management for access to medically necessary services
    4+Chronic conditions indicating potential referral
    3+ / 12 moAdmissions indicating potential referral
    30 daysReadmission interval for same or similar condition
    >30 / quarterPrescription threshold for polypharmacy
    N/AMonitoring and reporting requirements

    Complex Case Management Identification

    Complex Case Management Identification

    Blue Shield Promise identifies Members who may benefit from complex case management through utilization management, clinical, quality, provider, and facility data. When a complex care need is identified, refer the Member to the Case Management Department for case management, care coordination, and timely access to medically necessary covered services.

    Member eligibility and referral pathways

    • Member is less than 21 years of age and requires assistance gaining access to medically necessary medical, behavioral health, dental, social, educational, or other services defined in 42 USC sections 1396d(a), 1396d(r), and 1396n(g)(2), and W&I Code section 14059.5(b). Case management and care coordination must ensure provision of medically necessary covered services identified in the Early Start program Individualized Family Service Plan (IFSP), with primary care physician participation.
    • Member is over 21 years of age and is identified as having specific complex needs.
    • A complex care need is identified through one or more approved UM identification sources.
    Policy Summary
    PayerBlue Shield of California Promise Health Plan
    PolicyUM Referral to Complex Case Management
    Policy CodePolicy N/A
    Change TypeAdministrative and reference update
    Effective Date5/19
    Next Review DateN/A
    Key ActionRefer members to the Case Management Department when a complex care need is identified through the listed indicators or chronic conditions.
    SourceLink
    On This Page
    Complex Case Management IdentificationReferral Indicators and ThresholdsReferral and Care Coordination ResponsibilitiesKey Terms

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Member is transitioning to or from a skilled nursing facility and requires coordinated case management or Transitional Care Services.
  1. Member is eligible for the California Children's Services (CCS) Program and requires coordinated services or joint case management.
  2. Member has developmental disabilities and requires coordination of services through complex case management.

    3. UM identification sources

    • Precertification data
    • Inpatient or concurrent review data
    • Prior authorization data
    • Hospital data
    • Quality Management (QM) referrals
    • Provider referral

    Indicators for Complex Case Management

    • Major organ transplant
    • Major trauma
    • Four (4) or more chronic conditions>= 4 chronic conditions
    • Three (3) or more inpatient admissions within a 12-month period>= 3 admits / 12 months
    • Readmission within 30 days of the last hospitalization with the same or a similar diagnosis or condition<= 30 days
    • Polypharmacy utilization consisting of more than 30 prescriptions per quarter> 30 prescriptions / quarter
    • Cancer diagnosis requiring multiple treatment modalities with complex coordination of care across multiple disciplines

    Examples of chronic conditions supporting identification

    • Diabetes
    • Renal failure
    • Hypertension
    • Pulmonary conditions, including COPD, pneumonia, asthma, respiratory failure, pulmonary hypertension, and Guillain-Barre syndrome
    • Cardiac conditions, including congestive heart failure (CHF), cardiomyopathy, and coronary artery disease (CAD)
    • Osteomyelitis
    • Rheumatoid arthritis
    • Systemic lupus erythematosus (SLE)
    • Multiple sclerosis
    • Parkinson's disease
    • Cirrhosis of the liver or chronic liver disease
    • Pressure ulcers
    • HIV
    • Metastatic cancer

    Skilled nursing facility transition coordination

    • Coordinate with facility discharge planners, care or case managers, or social workers to provide case management and Transitional Care Services during all transitions.
    • Assist the Member, or the Member's parent, legal guardian, or authorized representative, by evaluating medical needs and available care settings, including discharge to a home or community setting.
    • Coordinate referrals to In-Home Supportive Services (IHSS), community supports, Long-Term Services and Supports (LTSS), and other Home and Community-Based Services (HCBS), as applicable.
    • Refer the Member to the Complex Case Management Department.
    • Ensure timely transitions that do not delay or interrupt medically necessary services or care.

    Additional coordination requirements

    • For Members eligible for the California Children's Services (CCS) Program, coordinate services and joint case management among the Member's primary care physician, CCS providers, and the local CCS Program.
    • For Members with developmental disabilities, refer coordination of services to Complex Case Management. See UM Policy 10.2.52, Genetically Handicapped Persons Program (GHPP), for additional information.

    Referral Indicators and Thresholds

    Multiple chronic conditions
    ThresholdFour (4) or more chronic conditions
    Utilization frequency
    ThresholdThree (3) or more admissions within a 12-month period
    Readmission
    CriterionReadmission within thirty (30) days from the last hospitalization with the same or similar diagnosis or condition
    Polypharmacy
    ThresholdMore than 30 prescriptions per quarter

    Referral and Care Coordination Responsibilities

    Note

    Refer Members With Complex Care Needs

    When a complex care need is identified, refer the member to the Case Management Department for appropriate case management support.

    • Complex care needs may be identified through indicators such as major organ transplant, major trauma, four or more chronic conditions, three or more admissions within 12 months, readmission within 30 days for the same or similar condition, polypharmacy exceeding 30 prescriptions per quarter, or cancer requiring complex multidisciplinary coordination.
    Note

    Coordinate Skilled Nursing Facility Transitions

    During transitions to or from a skilled nursing facility, coordinate with facility discharge planners, care or case managers, and social workers to provide case management and Transitional Care Services throughout the transition.

    • Ensure timely transitions that do not delay or interrupt medically necessary services or care.
    • Refer the member to the Complex Case Management Department.
    Note

    Plan Discharge and Connect to Community Services

    When a member is discharged, evaluate the member’s medical needs and available care settings, including discharge to a home or community setting, and coordinate referrals to services that support the transition.

    • Coordinate referrals to In-Home Supportive Services (IHSS).
    • Coordinate with community supports, Long-Term Services and Supports (LTSS), other Home and Community-Based Services (HCBS), and other applicable services.
    • Assist the member, parent, legal guardian, or authorized representative with discharge planning.
    Note

    Coordinate California Children’s Services

    For members eligible for the California Children’s Services (CCS) Program, coordinate services and joint case management among the member’s primary care physician, CCS providers, and the local CCS Program.

    • Maintain coordination among the PCP, CCS providers, and the local CCS Program.
    Note

    Coordinate Services for Developmental Disabilities

    Refer members with developmental disabilities to Complex Case Management for coordination of services.

    • See UM Policy 10.2.52, Genetically Handicapped Persons Program (GHPP), for additional information.

    Key Terms

    Case management
    DefinitionServices that assist eligible individuals in gaining access to needed medical, social, educational, and other services.