Heart Failure

The prevalence of heart failure (HF) is estimated to be about 2% of the general population of the United States. According to data from the American Heart Association, approximately 5 million people are living with heart failure and over 550,000 new cases are being diagnosed annually. The estimated direct cost for heart failure in 2006 is $29.6 billion in the United States.

Blue Cross’ multidisciplinary team of healthcare professionals collaborate to ensure each enrollee receives a “whole-person” approach to their disease management by addressing clinical functional, financial, psychosocial, environmental and support system needs.

The Heart Failure Disease Management program’s objectives are consistent with those set forth by the American College of Cardiology/American Heart Association (ACC/AHA). The main objective is to reduce the burden of disease due to heart failure by optimizing patient self-care efforts to ultimately, improve the patient’s quality of life and to promote provider satisfaction.

Eligible Members

The program is available to Blue Cross and Blue Shield of Louisiana, HMO Louisiana, Inc. and Federal Employee Program (FEP) primary members 18 to 80 years of age.

The selection process for our Heart Failure program is based on hospital claims, encounters, and pharmacy and laboratory data. We analyze claims data to assess relative health risk, identify medical conditions and build a member-centric clinical profile.

The program is not available to members who have other insurance as primary, are being actively treated for cancer, a transplant recipient, have ESRD, HIV/AIDs, are a hospice care recipient or nursing home resident. This is a voluntary program and members may “opt out” of the program at any time.

Re-enrollment into Program

Heart Failure program members are re-enrolled based on nurse assessment for any of the following reasons:
  • Member requests re-enrollment
  • Physician refers member again
  • Member experiences a heart failure-related admission
  • If the member has any of the following:
      1. Increased relative risk scores
      2. More than two hospitalizations in 12 months
      3. Emergency room visits for heart failure-related complications
      4. Medication non-adherence (45-day-or-less gap in medication refills)

Our Care Management team includes physician advisors, registered nurses, pharmacists and behavioral health specialists.

Physicians receive the following when their patient enrolls:

  • Written or telephonic notification if their patient is receiving ongoing nurse calls along with the nurse's contact information.
  • Notification of their patients who may be in need of healthcare services via a care coordination nurse call.
  • Patient referral by Blue Cross nurses when member does not have an established patient-physician relationship.
  • Access to claims-based Blue Health Records with up to three years of claims history (through iLinkBLUE)

Clinical Guidelines

ICSI Guideline - Heart Failure in Adults, July 2013


American Heart Association

How can I contact a nurse?

If you wish to contact a nurse to inquire about our programs, please call the Case and Disease Management Unit at 1.800.317.2299.

To refer a member for a care management program:

Complete the CMDM Referral Form and fax it to 225.298.3184.