Chronic Care Management
Empowering Better Health with Chronic Care Management
Proactive, personalized care for patients with multiple chronic conditions—designed to improve outcomes, reduce hospital visits, and keep your practice connected and efficient.
Transform Chronic Disease Care with Advaa Health
Advaa Health enables physicians to provide structured, ongoing Chronic Care Management services that enhance outcomes for patients with multiple chronic conditions—while creating a steady, new revenue stream for your practice.
What is Chronic Care Management?
Chronic Care Management (CCM) is a Medicare-supported service that provides continuous, coordinated care for patients living with two or more chronic conditions such as diabetes, hypertension, or heart disease. It involves regular follow-ups, care planning, medication management, and communication between healthcare providers and patients—aiming to improve health outcomes, enhance quality of life, and reduce hospitalizations through proactive, personalized care.
Full Scope of CCM Services
Fully aligned with CMS 2025 guidelines
Comprehensive Care Planning
- Dynamic EHR-based plans covering, Problem lists & prognosis, Medication reconciliation, Psychosocial needs assessment, Measurable treatment goals
- Updated quarterly or with health changes
24/7 Care Coordination
- Transition management (hospital to home)
- Specialist communication
- Medication management & prior authorization support
- Community resource linking (transportation, meal services)
Patient-Centered Services
- Monthly 20+ minute clinical check-ins
- Customized self-management education
- Emergency care plan development
- Remote vital monitoring integration (BP, glucose, weight, pulse oximetry)
Compliance Infrastructure
- Automated consent documentation
- Audit-ready time logs
- Secure patient portal (HIPAA-compliant messaging)
Eligibility & Enrollment
Qualifying Patients
- Medicare Part B beneficiaries
- 2+ chronic conditions (e.g., diabetes, CHF, COPD)
- At significant risk of: Acute exacerbation, Functional decline, Hospitalization
Practice Requirements
- Provider-led care team
- EHR with care plan functionality
- 24/7 patient access (direct or contracted)
CCM Reimbursement Structure
| Service | CPT Code | Time | Reimbursement* |
|---|---|---|---|
| Base CCM | 99490 | 20+ mins | $62.34 |
| Complex CCM (MD/NP-led) | 99491 | 30+ mins | $85.12 |
| Additional Time | 99437 | 30+ mins | $47.88 |
Key Financial Benefits
-
Monthly billing for
continuous care -
No patient opt-out risk:
92% retention rate -
Zero upfront costs with
Advaa’s turnkey platform
- Monthly billing for continuous care
- No patient opt-out risk: 92% retention rate
- Zero upfront costs with Advaa’s turnkey platform
Why Partner with Advaa Health?
Boost your practice with Advaa Health’s all-in-one Chronic Care Management solution—designed for compliance, efficiency, and maximum reimbursements.
- End-to-End CCM Solution
- Certified care coordinators
- Automated eligibility screening
- Real-time reimbursement dashboard
- Consent management system
Performance Metrics
30-40%
Reduction in provider administrative burden
28 Days
average ROI for practices
>95%
Clean claims rate
Implementation
Frequently Asked Questions
Patients with two or more chronic conditions expected to last at least 12 months—and that place them at significant risk of health decline or functional limitations—are eligible for CCM under Medicare.
CCM helps patients better manage their health through consistent communication with their care team, improved medication adherence, and personalized care plans. It can lead to fewer hospital visits, better outcomes, and improved quality of life.
Physicians and practices offering CCM services can generate predictable monthly revenue while enhancing patient engagement and outcomes. Advaa Health’s CCM solution makes it easier to implement and bill for these services.
CCM is typically provided through monthly remote check-ins by clinical staff, care coordination activities, and 24/7 access to a healthcare provider. It can be delivered via phone, patient portals, or other digital tools—outside of traditional in-person visits.
Yes, Medicare beneficiaries may have a small monthly copay or coinsurance for CCM services, typically around $8–$12, depending on their supplemental coverage. However, many patients find the value in the added support and improved health outcomes to be well worth the small cost.
