Complex Case Management (Member Focus) Level of Service. Complex case management with member focus involves the active coordination of care and services with the member and between providers while navigating the extensive systems and resources required for the member. It includes comprehensive assessment, determination of available benefits, development and implementation of a complex case management plan directed at the member’s chronic health conditions. Complex case management targets members with two (2) or more disease states who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition or members who have had an inpatient hospital stay in the last ninety (90) days or members with high dollar claims of over one hundred thousand dollars (>$100,000) in six (6) months. The focus is on working with the providers to meet the needs of the individual through communication with the member, PMP (if applicable), other providers, and the member’s natural support system. The member’s active involvement will help members gain optimum health or improved functional capability, in the right setting and in a cost effective manner. At a minimum, the Contractor must provide complex case management services for members discharged from an inpatient psychiatric or substance abuse hospitalization, for no fewer than ninety (90) calendar days following that inpatient hospitalization. The Contractor must also provide complex case management services for any member at risk for inpatient psychiatric or substance abuse re-hospitalization. Care managers must contact members during an inpatient hospitalization, or as soon as practicable upon receiving notification of a member’s inpatient behavioral health hospitalization. The care manager must work with the hospital discharge planner, behavioral health provider case manager and/or natural supports (i.e. family) to ensure that an outpatient follow-up appointment is scheduled to occur no later than seven (7) calendar days following the inpatient behavioral health hospitalization discharge. The Contractor must ensure that lack of transportation is not a barrier to the member attending the appointment. Complex case management includes all of the services and benefits from disease management and care management. In addition, all members in complex case management with member focus must receive materials no less than monthly. Avoidance of unnecessary emergency department and inpatient hospitalizations and incr...
