Case Management
Definition
Case management is a payer-sponsored service where a nurse or care coordinator works with high-complexity patients to coordinate care, reduce wasteful services, and ensure appropriate service levels. A case manager oversees treatment plans, authorizations, and discharge planning for patients with complex medical needs.
Why It Matters
Case-managed patients have different authorization and billing requirements. Working with case managers ensures proper approval and prevents utilization denials. Case managers provide valuable insights into payer expectations for high-cost patients. Coordination with case managers improves both payment rates and patient outcomes.
How It Works
Insurance payers assign case managers to patients with serious chronic illnesses, complex surgical cases, or very high medical costs. The case manager reviews the patient's care plan, discusses treatment options with the clinical team, and identifies opportunities for more efficient care delivery. They oversee prior authorization requests, coordinate hospital admission and discharge, and may provide resources for alternative care settings. Case managers work to ensure medically necessary services are approved while preventing wasteful or redundant care. They maintain regular communication with providers and patients. When a case-managed patient is admitted to the hospital, concurrent review is performed by the assigned case manager. Case management services are typically free to patients and are intended to improve care quality and reduce overall costs.
Related Terms
When does a payer assign a case manager?
Payers assign case managers to high-risk or complex patients. Common triggers include multiple chronic conditions, recent hospitalization, high medical costs, terminal illness, or mental health conditions. Case management is designed to coordinate care and avoid unnecessary utilization. Ask the payer if a patient has been assigned a case manager.
How does case management affect billing?
Case management may require additional authorizations, more frequent utilization reviews, or specific discharge planning requirements. These requirements must be met for full reimbursement. Work closely with the assigned case manager to ensure all services are pre-approved and documented.
See How Altair Tracks Case Management Patients
Altair flags case-managed patients and reminds you to coordinate authorizations and requirements with the payer's case manager. See how it works.
This glossary is for informational purposes. Consult official billing guidelines and payer policies for definitive definitions. Last updated: 2026-04-06.