10.2.69 UM Referral to Complex Case Management Form

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Policy Title: UM Referral to Complex Case Management POLICY #: 10.02.69 Line of business: Medi-Cal Department Name: Utilization Management Original Date 2/08 Effective Date 5/19 Revision Date 12/18, 11/22, 11/23 VP Approval: Tracy Alvarez, VP, Medical Care Solutions Date of Approval: 6/16/2025 Medical Services/P&T Committee: (If Applicable) Jennifer Nuovo, MD Chief Medical Officer

Date of Committee Review: 6/16/2025

A. PURPOSE To describe the mechanisms Blue Shield of California Promise Health Plan (Blue Shield Promise) utilizes to identify potential members for referral to Complex Case Management. This process is achieved through multiple data sources identified via specific criteria and categories of disease states. This is in accordance with NCQA StandardPHM5, Element A.

B. DEFINITIONS

1. “Case management” means services which will assist eligible individuals in gaining access to needed medical, social, educational, and other services.

   C. POLICY Blue Shield Promise will provide case management to assist Members less than 21 years of age in gaining access to all medically necessary medical, behavioral health, dental, social, educational, and other services, as defined in 42 USC sections 1396d(a), 1396d(r), and 1396n(g)(2), and Welfare & Institutions (W&I) Code section 14059.5(b). Blue Shield Promise will provide case management and care coordination to the Member to ensure the provision of all medically necessary covered services identified in the Individualized Family Service Plan (IFSP) developed by the Early Start program, with primary care physician (PCP) participation. Blue Shield Promise will provide case management to assist Members over 21 years of age when identified with specific complex needs.

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UM identification sources include, but are not limited to, the following: • Precertification Data • Inpatient/Concurrent Review Data • Prior Authorization Data • Hospital Data • QM Referrals • Providers

Indicators for Complex Case Management include, but are not limited to, the following: • Major organ transplant • Major trauma • Four (4) or more chronic conditions • Three (3) or more admits within a 12-month period • Readmission within thirty (30) Days from last hospitalization 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 include, but are not limited to, the following: • Diabetes • Renal failure • Hypertension • Pulmonary: COPD, pneumonia, asthma, respiratory failure, pulmonary hypertension, Guillain-Barre syndrome • Cardiac: CHF, cardiomyopathy, CAD • Osteomyelitis • Rheumatoid arthritis • Systemic Lupus Erythematosus (SLE) • Multiple Sclerosis • Parkinson’s Disease • Cirrhosis of liver/chronic liver disease • Pressure ulcers • HIV • Metastatic cancer

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D. PROCEDURE I. When a complex care need is identified from the above sections (Indicators for Complex Case Management or Chronic Conditions), a referral will be made to the Case Management Department. II. When transitioning Members to and from skilled nursing facilities, Blue Shield Promise will ensure timely Member transitions that do not delay or interrupt any medically necessary services or care by meeting the following requirements, at a minimum: a. Coordinate with facility discharge planners, care or case managers, or social workers to provide case management and Transitional Care Services during all transitions; b. Assist Members being discharged or Members’ parents, legal guardians, or authorized representatives by evaluating all medical needs and care settings available including, but not limited to, discharge to a home or community setting, and referrals and coordination with In-Home Supportive Services (IHSS), community supports, Long-Term Services and Supports (LTSS), and other Home and Community Based Services (HCBS); c. Refer member to Complex Case Management Department. III. When a member is eligible for the California Children’s Services (CCS) Program, Blue Shield Promise will ensure the coordination of services and joint case management between the Member’s PCP, CCS Providers, and the local CCS Program. IV. When a member has developmental disabilities, coordination of services will be referred to complex case management. See UM Policy 10.2.52 Genetically Handicapped Persons Program (GHPP) for more information. E. MONITORING N/A F. REPORTING N/A

G. ATTACHMENTS

1. NA

   H. REFERENCES

2. 42 USC sections 1396d(a), 1396d(r), and 1396n(g)(2)
3. NCQA Standard PHM5, Element A
4. UM Policy and Procedure 10.2.52 GHPP
5. Welfare & Institutions (W&I) Code section 14059.5(b)

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I. REVISION HISTORY

Date Modification (Reviewed and/or revised) E-Filing Number 06/2025 Annual Review

06/2024 Updated Approver 11/2023 Annual Review • Annual Review of Regulatory Requirements DHCS, DMHC, NCQA • Formatting updates • Grammatical changes • Updated NCQA reference 11/2022 Annual Review • Updated Policy Numbering to reflect Medi- Cal Only; • Annual Review of Regulatory Requirements DHCS, DMHC, NCQA