Chronic Care Management (CCM) is a reimbursable care coordination program designed to support patients with two or more chronic conditions. It enables providers to deliver ongoing, non-face-to-face clinical support to improve patient outcomes, reduce hospitalizations, and generate recurring revenue.
Chronic Care Management
Chronic Care Management (CCM) Primer
Empowering Healthcare Facilities to Deliver Better Outcomes With Zero Operational Burden
- Earn monthly reimbursements per patient
- Improve outcomes with proactive care coordination
- Offload your team with our white-labeled solution
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What is Chronic Care Management?
Our Approach: End-to-End CCM Management for Your Facility
We partner with healthcare facilities to implement a turnkey CCM program that operates as a seamless extension of your care team. Our process is designed to deliver value without disrupting your existing workflows:
1. Patient Panel Access & Eligibility Screening
We begin by obtaining access to your EHR system or a flat file export of your active patient panel. Using CMS guidelines, we cross-reference and identify patients who meet CCM eligibility criteria:
- Patients with two or more chronic conditions expected to persist for at least 12 months
- The patient must have had a qualifying face-to-face visit-such as an Evaluation & Management (E/M) visit, Annual Wellness Visit (AWV), or Initial Preventive Physical Examination (IPPE)-with the billing practitioner within the past 12 months.
2. Patient Outreach & Enrollment
Once eligible patients are identified, we launch a personalized outreach campaign using a dedicated phone number branded with your facility’s name as the caller ID. Our team educates patients on the benefits of the program and obtains verbal consent to enroll, ensuring a smooth onboarding process.
3. Comprehensive Care Plan Creation
After enrollment, we conduct a one-on-one consultation with the patient to develop a personalized care plan that includes:
- Chronic Diagnoses • Active Medications • Measurable Health Goals
- Lifestyle Recommendations • Health Considerations
4. Monthly Follow-Up & Ongoing Support
Each month, our Patient Care Coordinators (PCCs) engage in follow-up calls with enrolled patients to:
- Track progress • Coaching & Support • Medication Adherence
- New Concerns & Symptoms • Care Plans & Monthly Service Summaries
Our proprietary AI-driven software empowers our PCCs to work more efficiently and have more targeted, meaningful conversations with patients. By surfacing key health insights and care plan gaps in real time, the platform ensures a more personalized, data-informed experience for every patient interaction.
5. Billing & Documentation Support
Accurate documentation is essential for compliant billing and sustained program success. Our proprietary software tracks all patient interaction time, health data, and clinical notes to ensure that the adequate service time is provided for each patient to achieve their CCM goals. Our team is also able to upload notes directly into the facility’s EHR dependent on adequate access.
At the end of each month, the system automatically generates a comprehensive superbill tailored to your facility, clearly outlining the appropriate CPT codes and service details. This eliminates guesswork and streamlines the reimbursement process, helping you maximize revenue while staying fully compliant.
How It Works (In Plain English)
Your patients use easy-to-use medical devices at home—like a blood pressure cuff or glucose meter.
No apps, no setup—the device automatically sends the readings to our platform.
Your staff can see the data in real-time, check on any issues, and spend a few minutes each month reviewing it with the patient.
Our platform tracks everything, makes sure you’re compliant, and at the end of the month—you bill Medicare and get paid. Simple for the patient. Easy for your team. Revenue for your practice.
Frequently Asked Questions
How long does onboarding take?
Once we receive your patient list or EHR access, we can begin outreach within 7 days. Most clinics are fully live within one week.
Why is there an initiation fee?
The fee covers the setup of a HIPAA-compliant database, eligibility screening, and patient enrollment — all critical work done before we generate billable service time.
Why do you need EHR access?
EHR access lets us document directly, improving compliance, audit readiness, and continuity. If preferred, we can also work from a patient panel in Excel format.
How do we bill for services?
We send monthly time logs, care summaries, and superbills. You can submit these to your billing team or we can coordinate directly with them for smoother reimbursement.
What if patients don’t answer?
We make multiple call attempts per month, including after-hours and weekends if needed. Every outreach is logged and counted toward CMS billing thresholds.
Should we start with RPM or CCM?
We recommend starting with CCM due to simpler setup. RPM and other coordination services can be added once workflows are established.
How do you ensure compliance?
All calls are recorded. Our licensed team follows CMS and HIPAA standards for every service, with monthly reporting and documentation for audit-readiness.
What happens if we stop working together?
You’ll retain full access to all care summaries and patient data. That said, we’re confident you and your patients will love the program—so we don’t expect you’ll need to stop.
Increase your RPM revenue today
CPT 99453(~$19) Initial Device Setup
This is a one-time billable service for setting up a remote monitoring device (like a blood pressure cuff) and teaching the patient how to use it. It’s billed once at the beginning of care.
CPT 99454(~$43) Device Data Transmission
This monthly billable code covers the supply of the device and the automatic transmission of health data (e.g., at least 16 days of readings in a 30-day period). It’s billed every 30 days as long as the device is active and transmitting.
CPT 99457(~$48) 20-Minute RPM Monitoring & Communication
This is billed monthly when clinical staff or the provider spends 20 minutes reviewing the patient’s data and interacting with the patient in real time. It must include live communication (e.g., phone or video call).
CPT 99458(~$38) Each Additional 20 Minutes
This add-on code is billed alongside 99457 when more than 20 minutes of monitoring and communication is provided in the same calendar month
Why Choose RLH Health?
Instant EHR Integration
Automatically sync patient data directly into your existing workflow—no manual entry required.
Transparent Billing Guidance
Know exactly what CPT codes apply, why they apply, and how to maximize your reimbursements.
Rapid Onboarding
Go from discovery to billing within a single week. No delays, no hassles.
Zero Risk & No Cost
All devices, training, and integration are completely free. You pay nothing upfront.
Clinic Onboarding Checklist
Understanding the process
01
Agreements Submitted
- Send back your signed Services Agreement and BAA to begin onboarding.
- We’ll begin initial processes and lock your clinic into our Week 1 launch window.
02
Panel or EHR Access
- Upload a list of active patients or grant EHR access.
- We’ll use this to identify and enroll eligible individuals.
03
Dedicated Care Line Setup
- We’ll activate and configure your clinic’s outbound patient line.
- This number will be used by our care team for monthly outreach.
04
Clinic Contact Assigned
- Let us know who we’ll coordinate with during onboarding.
- This person will receive updates, reports, and care alerts.
05
Patient Outreach Begins
- Our team begins calling eligible patients within 7 days of onboarding.
- All calls are recorded and made from your branded clinic line.
06
Billing & Care Summaries
- We’ll upload monthly time logs, care summaries, and a detailed superbill.
- We can work directly with your billing team to ensure proper reimbursement
Ready to Start?
Schedule your quick, no-obligation discovery call today—and start billing CCM, RPM, PCM, or BHI within your first 30 days.