Chronic Care Management (CCM)
Designed to reimburse providers for treating patients with a single chronic condition over an extended period
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 monitoring team of nurses and MAs monitors your patients 24/7, responding to readings, calling, assessing and escalating relevant cases to you.
- 24/7/365 coverage in all states
- English and Spanish speaking
- Follow clinic-guided escalation processes
- Scale your RPM/CCM program without hiring additional staff
- Operates as an extension of your practice
Our Software
Your team will have access to our web-based, HIPAA-compliant RPM/CCM platform which serves as the hub for both programs.
- Integrates with cloud-based EHRs
- Time stamps and records patient interactions
- Generates billing reports
- Receives patient vitals
- Records clinical staff notes
EMR Integrations
