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For Health Professionals

Case Management

A comprehensive Plan of Care for Members at risk for or with complex medical needs due to illness, accident, or injury.


Recovery is Our Top Priority

Capital BlueCross recognizes that Members with complex medical needs often require a wide variety of resources and specialized information to help manage their health and improve their quality of life. Our Case Management program can help you and your Members to get the special attention they need and Case Management services are part of their insurance coverage so there's no extra charge for the service.

Case Manager's Role

A Case Manager is a specially trained professional - generally a registered nurse or occasionally, a social worker - who works with you and your Members to help coordinate their care. The Case Manager provides the Member with information about their care options so that they can make informed decisions about their own health care needs. The Case Manager encourages Member involvement and assists them as they make important choices and carry out the their plan of care.

The Case Manager will work with the Member to develop a customized plan for the complex array of services their special case requires. Our efforts are focused on making sure that the care is administered in an efficient and effective manner. The Case Manager can assist in identifying the services available and provide options to maximize covered benefits.

Plan of Care

The Case Manager will consult with the Member and medical team to develop a Plan of Care tailored to their needs. The Plan of Care will include an evaluation of the anticipated medical procedures, expected recovery time and the medical, family and community resources available. Communication between the Case Manager and others involved in the treatment is very important to the Member's recovery.

Who Qualifies for Case Management?

Your Capital BlueCross Member may benefit from Case Management if:

  • They have been diagnosed with a serious medical condition

  • They have multiple injuries or medical problems

  • They may be at risk for a future adverse health event due to an existing medical condition

  • They are undergoing an extended hospital stay

  • They are seeing several doctors

  • They have had recurring re-admissions for a single diagnosis

  • They may need an organ transplant

  • Their condition renders them incapable of performing daily independent living activities

Communication is Key

The Case Manager knows what questions to ask, where to find answers to questions and how the pieces fit together. Generally, the Case Manager may contact the member and treatment team by telephone and in writing, but can also arrange to visit the Member at home or at the hospital. Case Managers are available by phone during normal business hours, and have voicemail for you to leave messages if they aren't available when you call.

All this adds up to one thing: sensitive, caring professionals helping Members and their loved ones through the treatment and recovery process.

Care Management Initiation

Our Member's recovery is our top priority. If you would like to benefit from the Case Management program, you may contact the Capital BlueCross Case Management staff at 1.888.320.BLUE.

You may also request Care Management by submitting the Care Management Initiation Form that will be submitted directly to Capital BlueCross.