Complex case definition
Examples of Complex case in a sentence
Complex case management care plans will include all elements of disease management and care management, as well as higher levels of support.
Complex case management includes all of the services and benefits from disease management and care management.
Complex case management with provider focus is the active coordination by the Contractor of care and services between providers while navigating the extensive systems and resources required for the member.
Complex case management services are defined by multiple medical needs, high risk issues such as significant deterioration in health status or ongoing lack of self-management skills due to personal issues, cognitive impairment, mental illness, lack of social supports, or multiple co-morbidities.
Complex case management with a provider focus is appropriate for members who either choose not to be actively involved or are unable to actively participate in their health care.
Complex case management with provider focus includes all of the services and benefits from disease management and care management.
In accordance with 42 CFR 438.10(d), the Contractor must arrange for oral interpretation services to its members free of charge for services it provides, including: • Member services helpline as described further in Section 4.6.1; • Twenty-four (24) hour nurse call line; • Transportation; • Assessment and stratification; • Disease management; • Care management; • Complex case management; and • Right Choices Program.
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 conditions or members who have had an inpatient hospital stay in the last ninety (90) days or members with high dollar claims of over fifty thousand dollars (>$50,000) in six (6) months.
Complex case management services are defined by multiple medical needs, high risk issues such as significant deterioration in health status or ongoing lack of self- management skills due to personal issues, cognitive impairment, mental illness, lack of social supports, or multiple co-morbidities.
In accordance with 42 CFR 438.10(d), the Contractor must arrange for oral interpretation services to its members free of charge for services it provides, including: Member services helpline as described further in Section 4.6.1; Twenty-four (24) hour nurse call line; Transportation; Assessment and stratification; Disease management; Care management; Complex case management; and Right Choices Program.