Complex Case Management Trigger Events and Diagnosis Codes Adult/Pediatric/High-Risk Maternity

Horizon Blue Cross Blue Shield of New Jersey’s Complex Case Management Program is a free, voluntary service that offers care coordination and guidance to our members and their covered dependents when faced with a serious illness or condition. The member’s physician and a Horizon BCBSNJ Care Manager will work collaboratively with the member to develop a treatment plan. The treatment plan will consist of both short- and long-term goals for our members or their covered dependents to achieve self-management of the illness or condition.

Horizon BCBSNJ identifies members for the Complex Case Management Program from many sources, including:

• Physician referrals
• Member self-referrals
• Predictive modeling
• Daily discharge logs
• Weekly re-admission reports

Below is a partial list of trigger events and diagnosis codes for Complex Case Management services for adult, pediatric and high-risk maternity members. Triggers can be a diagnosis, an event, a circumstance or a behavior that represents an opportunity for case management intervention.

Horizon BCBSNJ reserves the right to modify this list at any time

Trigger Events and Circumstances

Trigger Diagnosis

The ICD-10 codes below may qualify for
Complex Case Management