Chronic Care Management (CCM)

Designed to reimburse providers for treating patients with two chronic conditions over an extended period of time. 

What is Chronic Care Management?

Initial Consultation and
Risk Assessment

We provide a monthly phone call conducted by one of our RNs. We first identify the patient’s risk level based on a thorough questionnaire and based on this assessment, established the patient’s health-related goals.

Ongoing 24/7/365
Patient Support

In addition to 24/7/365 text and call support, our RNs will help schedule doctors appointments, provide ongoing education, ensure medication adherence and provide ongoing accountability.

Bill the Payer for
Providing CCM

Our clinical interactions with your patients generates time towards the time-based CCM codes that you will bill Medicare (or other payer) for monthly. We help you with billing details so that you can generate clean claims.

Who monitors the patient data?

Our Clinical Team

Our Clinical Team

Our clinical monitoring team of nurses and MAs monitors your patients 24/7, responding to readings, calling, assessing and escalating relevant cases to you.

Our Software

Your team will have access to our web-based, HIPAA-compliant RPM/CCM platform which serves as the hub for both programs.

Our Software

EMR Integrations

OVER 50+ INTEGRATIONS

Enhanced Patient
Engagement.
Enhanced Care.

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