Premera Blue Cross Medicare Advantage Plans
Care Management Referral
Phone: 855-339-8127
Date and time of referral:
Fax: 855-339-9713
Intake person:
Patient name:
Identification number:
Sex:
M
F
Date of birth:
Primary care provider:
Physician group:
Patient phone:
Patient history/reason for referral to
Care Management:
Care Management Referral Indicators
Complex hospital stay with multiple ongoing
service coordination needs
Unplanned hospitalizations or readmissions
(2 within 30 days)
Catastrophic event/trauma with ongoing
coordination needs (adult and pediatric)
Complex care needs
Transition of care (new member)
Physician phone:
Fax:
Age- or Disease- Specific Referral Indicators
High-risk neonates/pediatrics
Transplant
End-stage renal disease
Cancer
Chronic obstructive pulmonary disease (COPD)
Heart failure
Diabetes
Coronary artery disease (CAD)
Maternity care management
Rare Diseases
Auto-immune disorders
Hereditary condition
Chronic inflammatory condition
Urgent need (within 24 hours)
Routine (within 48 hours)
Person requesting referral:
Phone:
Care Management Department use only below this text
Asthma
ESRD
Heart failure
Transplant
Cancer
Transition of care
An Independent Licensee of the Blue Cross Blue Shield Association
COPD
CAD
Pediatrics
Pain management
Maternity
Complex CM
Diabetes
Care coordination
Rare disease
030388 (08-2014)