Common use of Complex Case Management - Provider Focus Clause in Contracts

Complex Case Management - Provider Focus. Care plans for members needing complex case management but who are unable or unwilling to actively engage will focus on the needs of the individual through communication with the PMP (if applicable), other providers and the member’s natural supports system. The complex case management plan will identify the problems, barriers and issues related to the individual’s health care needs and recognize why, due to the person’s condition or other reasons, the member cannot actively participate. It will address goals, objectives and interventions to meeting the needs of the individual. In contact with the member, the member may not be actively engaged in coordinating with their medical team, however, the Contractor must engage the member in learning about the member’s health condition and follow the case management plan developed.