Name of Manual - Blue Cross and Blue Shield of Minnesota

Integrated Health Management
Integrated Health Management
Introduction As part of your participation agreement with Blue Cross and Blue
Shield of Minnesota (Blue Cross), you have agreed to comply with
Integrated Health Management programs administered by Blue
Cross and Blue Plus. These Integrated Health Management
programs are designed to ensure that the treatment members
receive is reimbursable according to the medical necessity
guidelines in their contracts. In addition, we review investigative
and new procedures/services for coverage determinations.
Integrated Health Management programs also ensure the most
cost-effective and appropriate use of the health care delivery
system.
These programs include:
Pre-Certification/Authorization of selected procedures,
services, supplies, and drugs
Preadmission Notification (PAN), Pre-Certification and
concurrent reviews for selected inpatient admissions
Case and Disease Management
Retrospective review of claims and medical records
To make utilization decisions, Blue Cross uses written utilization
review decision criteria based on sound clinical evidence. The
criteria used to evaluate an individual case is available, free of
charge, upon request for your review.
Objectives Integrated Health Management Programs are designed to:
Maximize the coordination of care and health outcomes.
Ensure appropriate and efficient utilization of health care
resources.
Promote efficient use of health care resources.
Define and agree upon appropriate standards of care.
Manage service for members with complex care coordination
needs.
Identify gaps in our members’ care and navigation of
resources.
Identification of members with conditions that will benefit
from self-care efforts, care intervention and communication.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-3