Disease Management and Population Health
Our Disease Management (DM) department is based on a system of coordinated care management interventions and communications designed to assist physicians and others in managing patients with chronic conditions.
The mission of the DM department is to improve the health and quality of life for Highmark Blue Cross Blue Shield of Western New York members by encouraging patient self-care efforts, coordinating health care education and providing interventions along the continuum of care.
Disease management services include:
- A holistic, member-centric approach to DM focusing on the needs of the member through telephonic and community-based resources.
- Motivational interviewing techniques used in conjunction with member self-empowerment.
- The ability to manage more than one disease to meet the changing health care needs of our member population.
- Weight management and smoking cessation education.
We have disease management programs for:
- Bipolar disorder.
- Coronary artery disease (CAD).
- Congestive heart failure (CHF).
- Chronic obstructive pulmonary disease (COPD).
- Major depressive disorder (MDD) — adults.
- Major depressive disorder (MDD) — children and adolescents.
- Substance use disorder (SUD).
Our programs feature:
- Proactive population identification processes.
- Evidence-based national practice guidelines.
- Collaborative practice models to include physician and support-service providers in treatment planning for members.
- Continuous patient self-management education (including primary prevention, coaching healthy behaviors and compliance or monitoring) and care management for high-risk members.
- Ongoing communication with primary and ancillary providers regarding patient status.
- NCQA accreditation for nine of our programs, which incorporate outreach, education, care coordination and follow-up to improve treatment compliance and enhance self-care.
Disease Management aims to:
- Address gaps in care.
- Improve the understanding of disease processes.
- Improve the quality of life for patients.
- Develop patient-centered goals and interventions.
- Support network provider relationships with patients.
- Increase network provider awareness of DM programs.
- Reduce acute episodes requiring emergent or inpatient care.
- Identify barriers to health care and address them by referring patients to appropriate community resources.
What are the benefits of collaborating with DM?
- Maximize your time — If you have patients with one or more of the conditions listed above who could benefit from additional education or care management, we encourage you to refer them to DM.
- Collaborative treatment plans — DM invites your input for patient treatment plans. We provide you with DM information and the most up-to-date Clinical Practice Guidelines (CPGs) to assist you in creating an individual plan of care.
- CPGs are available on the secure provider website (login is required). CPGs can also be requested at any time.
- Receive feedback on your patients between appointments — Providers can Patient360 link to Patient 360 page to obtain feedback on members regarding their care plans and condition management while enrolled in DM.
How can I refer a member to DM?
To refer a member, fax a completed Disease Management Referral Form to 1-888-762-3199 or send via Availity.
Hours of operation
DM care managers are registered nurses and are available from 8:30 a.m. to 5:30 p.m. local time, Monday through Friday. Confidential voicemail is available 24 hours a day. The 24/7 NurseLine is available for our members.
Please call 1-888-830-4300 to reach a DM care manager.
Provider rights and responsibilities
As a provider with patients enrolled in a DM program, you have additional rights and responsibilities such as the right to:
- Obtain information about the organization’s services, staff qualifications and any contractual relations.
- Decline to participate in or work with the organization’s programs and services on behalf of their patients.
- Be informed how the organization coordinates interventions with care plans for individual patients.
- Know how to contact the care manager responsible for managing and communicating with their patients.
- Be supported by the organization when interacting with patients to make decisions about their healthcare.
- Receive courteous and respectful treatment from the organization’s staff.
- Communicate complaints regarding DM as outlined in Provider Complaint and Grievance Procedure.
These rights and responsibilities are available to you in written format upon request to DM by calling 1-888-830-4300.
Provider tools and resources
- Log in to Availity
- Launch Provider Learning Hub Now
- Learn about Availity
- Precertification lookup tool
- Precertification requirements
- Claims overview
- Member eligibility & pharmacy overview
- Provider manual and guides
- Training Academy
- Pharmacy information
- Electronic Data Interchange (EDI)