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Home-based servicesFor chronic condition monitoring and surgical decision supportand for authorization determinationsRevised June 2021CARE MANAGEMENT AND UTILIZATION MANAGEMENTBlue Cross and BCN offer care management programs to members.These programs vary based on member coverage and may be administered by Blue Cross orBCN staff or by contracted vendors. Care management programs provide patient support by identifying patients with healthrisks and working with them to improve or maintain their health. Utilization management programs focus on ensuring that patients get the right care at theright time in the right location through the authorization process.These programs are provided by the vendors listed below.Care management Genex Services LLC PopHealthCare Utilization management CareCentrix Keep reading to learn which members have access to or requirements under these programs.Programs may not apply to all members.This document is subject to change. Access this document via ereferrals.bcbsm.com to ensureyou’re viewing the most up-to-date information.1
Home-based servicesFor chronic condition monitoring and surgical decision supportand for authorization determinationsRevised June 2021CARE MANAGEMENTGenex Services LLCResourcesProvides in-home assessments for members with complex medicalconditions who are at high risk for inpatient admissions or emergencyroom visits. The in-home assessment includes a medicationreconciliation and an environmental risk assessment. genexservices.com/** genex-catastrophic-injury-management**Genex also provides these programs: Catastrophic care management: Provides support for memberswith high acuity and complex needs. Life care plan: Estimates the projected life-long cost of care.To be eligible for these services, members must be engaged in theBlue Cross Coordinated Care program.Genex provides these services for the following groups and individualmembers, when they’re referred by Blue Cross Coordinated Carestaff: Blue Cross commercial Most fully insured groups — Exception: Michigan EducationSpecial Services Association Most self-funded groups* — Exceptions: Select Ascensiongroups, Dart Container of Michigan and UAW RetireeMedical Benefits Trust All members with individual coverageBCN commercial — All fully insured groups, all self-fundedgroups* and all members with individual coverage2
Home-based servicesFor chronic condition monitoring and surgical decision supportand for authorization determinationsRevised June 2021CARE MANAGEMENTPopHealthCare Through their CareSite program, PopHealthCare provides in-homevisits and phone-based care coordination by a team that includesnurse practitioners, physicians and registered nurses.The program provides support that helps members: Monitor chronic conditions Prevent exacerbations Identify acute problems Develop self-management skills Address advance directivesPopHealthCare provides these services to the following groups andindividual members: Medicare Plus BlueSM — Some groups and some members withindividual coverageResourcespophealthcare.com**3
Home-based servicesFor chronic condition monitoring and surgical decision supportand for authorization determinationsRevised June 2021UTILIZATION MANAGEMENTCareCentrix For BCN AdvantageMakes authorization determinations and supports the coordination ofhome health care, such as skilled nursing and physical, occupationaland speech therapies. BCN Home health care page on the ereferrals.bcbsm.comwebsite See the “Guidelines for transitional care” section in the UtilizationManagement chapter of the BCN Provider ManualCareCentrix provides these services for the following products: Medicare Plus Blue — All groups and all members with individualcoverage BCN AdvantageSM — All groups and all members with individualcoverageResources carecentrixportal.com/ProviderPortal** Home health care: Frequently asked questions for providersFor Medicare Plus Blue Blue Cross Home health care page on the ereferrals.bcbsm.comwebsite In the “Utilization management” section of the Medicare Plus BluePPO Manual, see the “Prior authorization process for homehealth care” subsection4
Home-based servicesFor chronic condition monitoring and surgical decision supportand for authorization determinationsRevised June 2021ADDITIONAL INFORMATIONAbout this documentReminderThis document lists coverage exceptions for major groups.As always, it’s essential that providers check each member’seligibility and benefits prior to performing services.It also provides links to additional resources, some of which may bein provider manuals that aren’t publicly available. To access chapters of the Blue Cross PPO Provider Manual, login as a provider at bcbsm.com, click the Provider Manuals link onthe right and then click the Blue Cross PPO Provider Manual link. To access chapters of the BCN Provider Manual, log in as aprovider at bcbsm.com, click the Provider Manuals link on theright and then click the BCN Provider Manual link.Providers are responsible for identifying the need for authorizationthrough web-DENIS, Benefit Explainer or Provider Inquiry and forcontacting vendors and obtaining authorization for services, asneeded.Information for out-of-state providersSee the following documents for referral and authorizationrequirements. For Blue Cross commercial and Medicare Plus Blue members:Provider Preauthorization and Precertification Requirements For BCN commercial and BCN Advantage members: NonMichigan providers: Referral and authorization requirementsYou can view these documents and our medical policies through theMedical Policy & Pre-Cert/Pre-Auth Router. To access the router, goto bcbsm.com/providers, click Quick Links, click Out-of-stateproviders and then click Medical policy, precertification andpreauthorization router.*For self-funded plans, the employer assumes the risk for claims costs andpays a fee for administrative services provided by Blue Cross or BCN.**Clicking this link means that you're leaving the Blue Cross Blue Shield ofMichigan and Blue Care Network website. While we recommend this site,we're not responsible for its content.5
The program provides support that helps members: Monitor chronic conditions Prevent exacerbations Identify acute problems Develop self-management skills Address advance directives PopHealthCare provides these services to the foll
