Case management

Humana Military nurses provide case management services for TRICARE beneficiaries with complex health needs. The following conditions warrant mandatory referral to case management:

  • Transplant evaluation or procedure (solid organ or bone marrow/peripheral stem cell)
  • Ventilator dependence
  • Acute inpatient rehabilitation (not skilled facility with therapy only)
  • Traumatic brain injury, spinal cord injury, stroke, new blindness
  • New quadriplegia or paraplegia
  • Premature infant: ventilator-dependent more than 24 hours and/or weight less than 1,500 grams
  • Planned Long-Term Acute Care (LTAC) admission
  • Catastrophic illness or injury, amputation, multiple traumas
  • Pregnancy with significant identified risks
  • Hourly nursing care more than four hours per day
  • Burn injury requiring a burn unit
  • Unplanned admissions to acute hospital three times or more within 90 days with the same diagnosis
  • Chronic condition resulting in high resource consumption (e.g., hemophilia, Gaucher’s disease)
  • ECHO requests
  • Transfer to a military hospital or clinic or network facility

This list is not all-inclusive and is subject to change. Beneficiaries with a complex case who may benefit from case management are eligible for an evaluation and providers should refer them to Humana Military.