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Case Management
Case Management is the focused arrangement of the sequence of services and resources necessary to
respond to the patient’s overall care requirements in catastrophic or complicated cases.
Case Management uses a team approach, which includes the Primary Care Physician, Specialist, Home
Health Agencies, Social Workers, family and others as appropriate. A collaborative approach is used to
assist in meeting the health care needs and community service needs of the Member on a short or long
term basis. The Primary Care Physician’s involvement in care of Members in case management is
essential to support improved Member outcomes.
The Case Management program strives to deliver access to quality care in the most cost effective
manner through appropriate utilization of all available health care resources. Members that can be
referred to Case Management include, but are not limited to, the following:
• Members discharged home from acute/sub-acute/skilled settings with specific ambulatory-sensitive
diagnosis such as DM, CHF, angina without procedure, and COPD
• Members with frequent readmissions
• Members in disease management programs to include, but not limited to, diagnosis of CHF or Diabetes
Mellitus
• Members enrolled in Special Needs Plans for Hypertension and Hyperlipidemia
• Members receiving intensive level of home health care
If you would like to refer a Bravo Health Member for Case Management services, please call 1-888-454-
0013, extension 336940.
Skilled Nursing Care
Bravo Health follows Medicare guidelines for skilled nursing care needs. All Members will be
reviewed and notified within two (2) days prior to the last covered approved day. Only the Medical
Director can deny skilled care based on medical necessity. If additional skilled services are denied, the
facility will be instructed to provide the Member and/or the authorized representative with notification
of the termination of skilled benefits.
Emergency Services
Bravo Health covers emergency services necessary to screen and stabilize Members without
preauthorization in accordance with applicable law. Bravo Health covers emergency services if a PCP
or other authorized representative acting on behalf of Bravo Health has directed the Member to the
Emergency Room.
In an emergency situation, Members sometimes self-refer without the knowledge of the Primary Care
Physician or Bravo Health. In such cases, the medical records will be reviewed retroactively. Final
determination regarding whether an emergency situation existed will be subject to review and will be
determined in accordance with applicable law.
The review is primarily used to promote high quality care, assess whether there is access to Primary
Care Physicians who are contractually obligated to provide care 24 hours a day, 7 days a week is
adequate, and increase awareness of appropriate use of costly emergency care resources.
