CCM Software & Services
Chronic Care Management Software and Services
HealthArc helps physician practices and health systems launch, run, and bill compliant CCM programs, with care plans, automated outreach, time tracking, and billing support built into one platform.
HIPAA Compliant
AICPA SOC 2 Certified
Primary care, cardiology, endocrinology & multi-specialty
$12.8K/mo200-patient panel
20 minauto-tracked / patient
100K+Patients Served
750+Happy Providers
40+States Covered
$62–64Avg. 99490 / patient / mo
Program Overview
What Is Chronic Care Management (CCM)?
CCM is a Medicare and Medicare Advantage program that reimburses eligible providers for non-face-to-face care coordination delivered to patients with two or more chronic conditions. It pays for the clinical time your team spends between appointments reviewing care plans, coordinating referrals, managing medications, and following up on results.
To qualify, patients must have two or more chronic conditions expected to last at least 12 months, placing them at significant risk of exacerbation, functional decline, or death. The primary code, CPT 99490, covers the first 20 minutes of clinical staff time and reimburses ~$62–$64 per patient per month. Because that coordination time is also what closes care gaps and prevents readmissions, CCM is one of the programs most often used to fund value-based care readiness.
Common Qualifying Chronic Conditions
Type 2 Diabetes
Hypertension
Congestive Heart Failure
COPD
Chronic Kidney Disease
Coronary Artery Disease
Depression / Anxiety
Hyperlipidemia
Atrial Fibrillation
Obesity (BMI ≥ 30)
Alzheimer’s / Dementia
Hypothyroidism
Osteoporosis
Asthma
Stroke / Cerebrovascular
Cancer (active / remission)
Patients must have 2 or more qualifying conditions and provide consent before CCM enrollment begins. HealthArc digitizes the consent workflow and stores an auditable record tied to each patient.
Who It’s For
Who Uses HealthArc for CCM?
Built for physician-led practices and care teams that want to add or expand a CCM program without building infrastructure from scratch.
Practice Types
- Independent primary care & internal medicine
- Multi-specialty group practices
- FQHCs and Rural Health Clinics (RHCs)
- Cardiology, endocrinology & nephrology
- Hospital-affiliated outpatient clinics
Roles on the Platform
- Physicians & NPs who supervise CCM
- Care coordinators & medical assistants
- Billing staff & practice administrators
- Compliance officers for documentation & consent
Patient Populations
- Adults 65+ on Medicare / Medicare Advantage
- Two or more chronic conditions
- High-risk patients between office visits
- 40–60% of a typical primary care panel
The Platform
CCM Software Built for Clinical Workflows
Every step of a compliant CCM program lives in one platform. Eligibility, consent, care time and billing reports in one place. No spreadsheets, no manual timers, no separate billing tools.
Patient Identification & Eligibility
Start with the patients you already have. Filter the panel by condition, payer and enrollment status, then flag everyone who qualifies today and isn’t being billed for, which in most practices is a larger number than anyone expects.
Digital Consent & Enrollment
Consent, captured electronically. Every record is timestamped and auditable, and you can send the form through the portal or collect it at the front desk.
Condition-Specific Care Plans
Editable CMS-compliant templates, by condition. Everyone works from the current version and every revision is dated, so there’s never a question about which plan was in force.
Monthly Outreach Tracking
Log calls, secure messages and check-ins. Each one lands on the monthly record with a timestamp and a running total toward the threshold.
Automated Time Tracking
In-platform time captures itself. Off-platform work goes in by hand, and at month end the totals map to whichever CPT code the minutes actually support.
Billing Report Generation
Minutes map to 99490, 99439, 99487 or 99491, and the export lands in your clearinghouse format with every required field already populated, so month-end becomes a review rather than a rebuild.
Population-Level Dashboard
Who’s enrolled. Who’s hit the threshold. Who’s about to miss the minimum with four days left in the month, which is the one you actually want to see.
Care Team Model
CCM Services: Care Coordination Support
No staffing capacity to run CCM internally? HealthArc supplements your team, or fully manages outreach on your behalf under physician supervision, so your program scales without proportional headcount.
Dedicated Care Coordinators
Trained coordinators handle the monthly outreach. They update care plans and document clinical time on your behalf, under physician supervision. You keep the clinical decisions and the NPI.
Enrollment Support
The onboarding team pulls your eligible panel and prepares the consent materials. They also make the first round of calls, which is usually where enrollment is won or lost.
Compliance Monitoring
Every patient’s monthly documentation gets checked against CMS requirements for the applicable code. Before billing closes, not after.
Billing Workflow Support
The team reviews monthly billing reports for accuracy and completeness before submission. Fewer denials. Fewer documentation gaps.
Program Performance Reviews
You sit down with us every quarter. Enrollment, revenue, what to expand next.
Physician Oversight
All services operate under the supervising physician’s NPI. Physicians set parameters and approve care plans. That satisfies CMS general supervision.
Billing & Reimbursement
CCM CPT Codes, Requirements & Reimbursement
CMS reimburses CCM through four primary CPT codes tied to time thresholds and complexity. HealthArc maps each patient’s monthly activity to the correct code automatically.
~$62–64
99490
First 20 Minutes: Clinical Staff
- 20 min clinical staff time / month
- Requires current care plan & consent
~$47–49
99439
Each Additional 20 Minutes
- Add-on to 99490
- Per extra 20-minute increment
~$130–135
99487
Complex CCM: First 60 Minutes
- Moderate-to-high complexity
- Physician / NPP directed
~$82–85
99491
30 Minutes: Physician / NPP
- Personally by physician / NPP
- Not billed with 99490 same month
Documentation Requirements
Five things a CCM claim has to be able to show if a payer asks. HealthArc captures each one as the work happens.
1
Documented patient consentVerbal is allowed, but it has to be in the record along with the patient’s right to stop at any time.
2
An initiating visitWithin the previous 12 months, with the billing practitioner.
3
A comprehensive care planCurrent, condition-specific, and revised rather than written once and left alone.
4
Monthly clinical staff time logsMeeting the threshold for the code billed, and never counted toward a second program.
5
Evidence of the coordinationThe calls, referrals and medication work the time was spent on.
Undocumented verbal consent is the single most common reason a clean-looking CCM claim gets pulled back on audit. HealthArc timestamps it at enrollment, so it never has to be reconstructed.
$12,400–$12,800per month · 200-patient panel on 99490
That is the base code alone, before add-on or complex CCM.
Where programs leave money behind. A patient who gets 45 minutes of coordination in a month supports 99490 plus a unit of 99439. If the time log stops counting at 20 minutes, that second code is never billed. Track the full month and the same panel pays more.
Average figures are national Medicare non-facility rates and vary by geography, payer, and year. Verify current rates via the CMS Physician Fee Schedule.
Implementation
From Contract to First Billed Patient
Most practices see their first CCM revenue within 60 to 90 days of kickoff. The process front-loads patient identification and enrollment so your team can focus on care.
1
Weeks 1–2
Discovery & Panel Analysis
HealthArc reviews your panel to identify CCM-eligible patients by diagnosis code and payer mix, with a billable-population and projected-revenue estimate before full rollout.
2
Weeks 2–3
Platform Configuration & EHR Setup
We configure your environment and connect your EHR for patient data sync. Care plan templates get tailored to your workflows and your specialty.
3
Weeks 3–4
Staff Training
Coordinators, billing staff and supervising physicians each get their own training track. Two to four hours per role. That’s the whole training commitment.
4
Months 1–2
Patient Consent & Enrollment
Your team (supported by HealthArc’s enrollment specialists if needed) obtains consent and completes initial care plans with provided scripts and tracking.
5
Months 2–3
First Billing Cycle
HealthArc generates your first CCM billing report at month-end, reviewed for completeness before submission. Most practices submit first claims within 60–90 days.
6
Ongoing
Ongoing Program Management
Platform and optional services support monthly outreach, care plan maintenance, time documentation, and billing, all reviewed quarterly with your team.
Interoperability
EHR Integration & Reporting
HealthArc connects with the EHR systems you already use. It pulls demographics, diagnoses, and medication lists, and pushes documentation back into the chart, so your team works from one unified view.
- Bi-directional sync with major EHR platforms (HL7 / FHIR)
- Diagnosis-code import for eligibility screening
- Care plan documentation written back to the chart
- Structured data import where APIs aren’t available, so there are no data gaps
Bi-Directional Sync
Demographics and diagnoses in; documentation out.
Direct API
Connects directly where EHR vendors offer open APIs.
Real-Time Reporting
Enrollment, billing progress, time logs & CPT distribution.
No IT Build
Minimal effort from your practice team.
Results
CCM Program Results with HealthArc
Chronic disease is the fastest-growing segment of the Medicare population, and most practices already have hundreds of eligible patients they aren’t yet billing for.
60–90Days to first billed CCM patient after kickoff
$12–18K+Est. monthly recurring revenue at 200+ enrolled patients
40–60%Share of a typical Medicare primary care panel eligible for CCM
50%of U.S. adults live with one or more chronic condition
Security
HIPAA Compliance & Data Security
Built to meet HIPAA Privacy and Security Rule requirements at the platform level, so your practice doesn’t build compliance infrastructure on its own.
Certifications
- HIPAA-compliant infrastructure; BAAs with every client
- AICPA SOC 2 Type II, annual independent audit
- Audit-ready, timestamped, immutable records
Data Security
- Encrypted in transit (TLS 1.2+) and at rest (AES-256)
- Role-based access controls per patient panel
- Access logs for all data and clinical actions
CMS CCM Compliance
- Delivered under the supervising physician’s NPI
- CPT thresholds enforced to prevent overbilling
- Templates meet CMS medical-record requirements for CCM
FAQ
Frequently Asked Questions
Answers to the questions practices most commonly ask when evaluating CCM programs and software vendors.
What is chronic care management software?
Chronic care management software is a digital platform that helps healthcare practices manage, document, and bill for CCM services required by CMS. It typically includes tools for identifying eligible patients, capturing consent, building and maintaining care plans, tracking monthly clinical staff time, logging care coordination activities, and generating billing reports tied to CPT codes 99490, 99439, 99487, and 99491. HealthArc is an example of a CCM software platform that also offers optional care coordination services.
How does CCM billing work, and which CPT codes apply?
CCM is billed monthly per eligible patient. The primary code, CPT 99490, requires a minimum of 20 minutes of clinical staff time per calendar month and reimburses approximately $62–$64 under Medicare national rates. Add-on code 99439 is billed for each additional 20 minutes of non-complex CCM time. CPT 99487 covers complex CCM requiring at least 60 minutes of moderate-to-high complexity care. CPT 99491 applies when the physician or non-physician practitioner personally spends at least 30 minutes. HealthArc’s platform tracks time against these thresholds and maps each patient’s monthly activity to the correct code at billing.
What EHR systems does HealthArc integrate with?
HealthArc supports integration with major EHR platforms used in primary care and specialty practices. Integration enables bi-directional data exchange: patient demographics and diagnoses flow into HealthArc for eligibility screening, and care plan documentation is written back to the EHR chart. Practices whose EHR does not support API integration can onboard via structured data import.
How many patients do we need to make CCM financially viable?
A CCM program becomes financially meaningful at roughly 50–75 enrolled patients billing CPT 99490 each month, generating approximately $3,100–$4,800 in monthly recurring revenue. At 200 enrolled patients, estimated monthly revenue reaches $12,400–$12,800 from the base 99490 code alone, before you count add-on codes or complex CCM patients. HealthArc’s revenue calculator can model your specific panel and payer mix.
Is a dedicated care coordinator required to run a CCM program?
Not necessarily. Practices with available clinical staff (medical assistants, LPNs, RNs, or care managers) can run CCM outreach internally using HealthArc’s platform. For practices without available staff, HealthArc offers a managed care coordination service in which trained coordinators conduct monthly outreach and documentation on behalf of the practice, under physician supervision, without requiring the practice to hire additional headcount.
How does HealthArc ensure CCM documentation meets CMS requirements?
HealthArc’s platform enforces CMS documentation standards at the workflow level. The system requires a current care plan, documented patient consent, and a minimum time threshold before a patient appears as billable in the monthly report. Time logs are tied to specific activity types and timestamped automatically. The resulting billing report includes all required documentation elements and is designed to withstand payer audit review.
How long does it take to launch a CCM program with HealthArc?
Most practices complete onboarding, including EHR integration, staff training, and initial patient enrollment, within four to six weeks. First CCM claims are typically submitted within 60–90 days of kickoff. HealthArc’s implementation team manages the technical setup and provides enrollment support to accelerate time to first billing.
Get Started
See HealthArc’s CCM Platform in Action
- How HealthArc identifies CCM-eligible patients in your panel
- The care plan and monthly outreach workflow your coordinators use
- How time is tracked and mapped to CPT codes
- What a completed billing report looks like before submission
- Revenue projections based on your patient volume
Schedule a Demo
Revenue Calculator
HIPAA Compliant • SOC 2 Certified • No long-term contracts
sales@healtharc.io • +1-201-885-5571
sales@healtharc.io • +1-201-885-5571
How can HealthArc help you?
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Resources
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Practical guidance on CCM programs, billing and patient engagement. Updated with every new post.
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