Personal Case Management (for Non-Medicare Members)
The Personal Case Management Program enables you to obtain medically appropriate care in a more economical, cost-effective and coordinated manner during prolonged periods of intensive medical care. Anthem Blue Cross, through a case manager, may recommend an alternative plan of treatment which may include services not typically covered under the Plan. Anthem Blue Cross does not have an obligation to provide personal case management. These services are provided at the sole and absolute discretion of Anthem Blue Cross. Examples of conditions that may fall under Personal Case Management include:
These Are Examples
These conditions or diagnoses are not a guarantee of acceptance into the Personal Case Management Program. Cases are reviewed and criteria applied to determine possible enrollment, and enrollment is contingent upon member consent.
  • Burns
  • CVA
  • Migraine
  • Sickle Cell Disease
  • Trauma
How Personal Case Management Works
You may be identified for possible personal case management through the Plan's utilization review procedures, by the attending physician or hospital staff, or through Anthem Blue Cross' claims reports. You or your family may also call Anthem Blue Cross and request personal case management.
Benefits for personal case management will be considered only when all of the following criteria are met:
  • You require extensive long-term treatment;
  • Anthem Blue Cross anticipates that such treatment utilizing services or supplies covered under the Plan will result in considerable cost;
  • A cost-benefit analysis determines that the benefits payable under the Plan for the alternative plan of treatment can be provided at a lower overall cost than the benefits you would otherwise receive under the Plan while maintaining the same standards of care; and
  • You (or your legal guardian) and your physician agree, in a letter of agreement, with Anthem Blue Cross' recommended substitution of benefits and with the specific terms and conditions under which alternative benefits are to be provided.
Alternative Treatment Plan
If Anthem Blue Cross determines that your needs could be met more efficiently, an alternative treatment plan may be recommended. This may include providing benefits typically not covered under the Plan. A case manager will review the medical records and discuss your treatment with the attending physician, you, and your family.
Anthem Blue Cross makes treatment recommendations only; you and your physician make the decisions regarding treatment. The Plan will not compromise your freedom to make such decisions.
The Effect Personal Case Management Has on Benefits
  • Any alternative benefits are accumulated toward the corresponding benefit maximums.
  • Benefits are provided for an alternative treatment plan on a case-by-case basis only. Anthem Blue Cross has absolute discretion in deciding whether or not to authorize services in lieu of benefits for any covered person, which alternatives may be offered and the terms of the offer.
  • The authorization of services in lieu of benefits in a particular case in no way commits the Plan to do so in another case or for any other covered person.
  • The Personal Case Management Program does not prevent Anthem Blue Cross from strictly applying the expressed benefits, exclusions and limitations of the Plan at any other time or for any other covered person.
Third Parties
Anthem Blue Cross reserves the right to use the services of one or more third parties in the performance of the services outlined in the letter of agreement. No other assignment of any rights or delegation of any duties by either party is valid without the prior written consent of the other party.