Chronic Care Management,

Taking your health to the next level.

Taking your to the next level.

The specialized healthcare you need, when you need it. 


CCM services may be furnished for Medicare patients with two or more chronic conditions who are at significant risk of death, acute exacerbation/decompensation, or functional decline.

CCM activities include those that support comprehensive care management for patients outside of the office setting. Services include interactions with patients by telephone or secure email to review medical records and test results or provide self-management education and support. Services also include interactions with the patient’s other healthcare providers to exchange health information, as well as management of care transitions and coordination of home- and community-based services. CCM requires that patients have 24/7 access to physicians or other qualified healthcare professionals or clinical staff to address urgent needs.

In addition to physician offices, CCM services can be provided by Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Critical Access Hospitals (CAHs). The following healthcare professionals can bill for CCM services:

  • Physicians
  • Physician Assistants
  • Nurse Practitioners
  • Certified Nurses
  • Midwives
  • Clinical Nurses Specialists
chronic care management resource poster

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