Chronic Care Management Software & Services

CMS reimburses practices for the time spent managing patients with two or more chronic conditions outside of office visits. HealthArc gives your care team the tools and workflows to deliver that care, document it correctly, and capture every dollar you've earned.

50% US adults experience
one or more chronic condition

7/10 Deaths among US adults
is by one of the chronic diseases.

100% Increase by 2050 with
adults suffering from chronic diseases

What Is Chronic Care Management (CCM)?

Chronic Care Management (CCM) is a Medicare and Medicare Advantage program established by the Centers for Medicare and Medicaid Services (CMS) that reimburses eligible healthcare providers for non-face-to-face care coordination services delivered to patients with two or more chronic conditions. CCM is distinct from office visits — it covers the clinical time your team spends between appointments: reviewing care plans, coordinating referrals, managing medications, and following up on test results.

To qualify, patients must have two or more chronic conditions expected to last at least 12 months or until death, and those conditions must place the patient at significant risk of acute exacerbation, functional decline, or death. Common qualifying conditions include type 2 diabetes, hypertension, heart failure, COPD, chronic kidney disease, depression, obesity, and hyperlipidemia. Patients must provide written or verbal consent before services begin.

CMS reimburses CCM services under several CPT codes depending on the complexity of care and the total clinical staff time spent per calendar month. The primary code, CPT 99490, covers the first 20 minutes of clinical staff time and reimburses an average of $62–$64 per patient per month. Practices with panels of 100 or more eligible patients can generate five- to six-figure monthly recurring revenue through a well-run CCM program.

HealthArc is a CCM software and services platform that gives practices the infrastructure to run these programs at scale — from patient identification and enrollment through care plan management, monthly outreach, time documentation, and billing report generation.

Common Qualifying Chronic Conditions

Type 2 Diabetes

Atrial Fibrillation

Hypertension

Obesity (BMI ≥ 30)

Heart Failure (CHF)

Alzheimer's / Dementia

COPD

Hypothyroidism

Chronic Kidney Disease

Osteoporosis

Coronary Artery Disease

Asthma

Depression / Anxiety

Stroke / Cerebrovascular

Hyperlipidemia

Cancer (active/remission)

Consent required: Patients must have 2 or more qualifying conditions and provide consent before CCM enrollment begins. HealthArc digitizes the consent workflow.

Who It’s For

Who Uses HealthArc for CCM?

HealthArc is built for physician-led practices and care teams that want to add or expand a CCM program without building infrastructure from scratch. The platform is used across a range of specialties and practice sizes

Practice Types

Independent primary care and internal medicine practices
Multi-specialty group practices and ACOs
Federally Qualified Health Centers (FQHCs)
Rural Health Clinics (RHCs)
Cardiology, endocrinology, and nephrology practices
Hospital-affiliated outpatient clinics

Roles That Use the Platform

Physicians and nurse practitioners who supervise CCM programs
Care coordinators and medical assistants who conduct monthly outreach
Billing staff and administrators who generate and submit CCM claims
Compliance officers responsible for documentation and consent records

Patient Populations Served

Patients with two or more Medicare-eligible chronic conditions
Adults 65+ on traditional Medicare or Medicare Advantage
Some commercial plans that reimburse CCM-equivalent programs
CCM-eligible panels: typically 40–60% of a primary care base

Platform

CCM Software Built for Clinical Workflows

HealthArc centralizes every step of a compliant CCM program in a single platform — from identifying eligible patients and capturing consent to documenting care time and generating billing reports. No patchwork of spreadsheets, no manual time logs, no separate billing tools.

STEP 1

Patient Identification and Eligibility

HealthArc surfaces patients in your panel who meet CCM eligibility criteria based on diagnosis codes. Filter by condition combinations, insurance type, and enrollment status to build your CCM roster quickly. The platform flags unenrolled patients so your team can prioritize outreach and consent.

STEP 2

Digital Consent and Enrollment

CMS requires documented patient consent before CCM services begin. HealthArc supports electronic consent capture directly within the platform, creating an auditable consent record tied to each patient's profile. Consent forms are customizable and can be delivered via patient portal or during an office visit.

STEP 3

Condition-Specific Care Plans

Every enrolled patient receives a structured, CMS-compliant care plan covering their active chronic conditions, medications, allergies, care goals, and scheduled follow-ups. HealthArc provides editable templates organized by condition, so care coordinators can build comprehensive plans in minutes rather than hours.

STEP 4

Monthly Outreach and Communication Tracking

Care coordinators use HealthArc to conduct and log monthly patient touchpoints — phone calls, secure messages, medication check-ins, and referral follow-ups. Every interaction is timestamped and attributed to the patient's monthly activity record. The platform tracks cumulative time automatically so coordinators know exactly how close each patient is to the 20-minute monthly threshold.

STEP 5

Automated Time Tracking

HealthArc auto-captures time spent within the platform — including time on care plan reviews, documentation, and patient communication — and surfaces it in a per-patient activity log. Manual time entries are also supported for phone calls and off-platform interactions. At month end, the system aggregates all logged time and maps it to the applicable CPT code.

STEP 6

Billing Report Generation

At the end of each billing cycle, HealthArc generates a structured CCM billing report that maps each patient's documented minutes to the correct CPT code (99490, 99439, 99487, or 99491). Reports are formatted for submission to your billing team or clearinghouse and include all required documentation fields.

STEP 7

Population-Level Dashboard

The practice dashboard gives administrators a real-time view of CCM program health: total enrolled patients, patients who have reached billing thresholds, patients at risk of falling short of the monthly minimum, and monthly revenue estimates. No end-of-month surprises.

CCM Services

CCM Services — HealthArc's Care Coordination Support

Not every practice has the staffing capacity to run a CCM program internally. HealthArc offers a care team support model that supplements your existing staff — or fully manages outreach on your behalf — so your program can scale without proportional headcount increases.

Dedicated Care Coordinators

Trained coordinators conduct monthly patient outreach, complete care plan updates, and document clinical time on behalf of your practice under physician supervision.

Enrollment Support

HealthArc's onboarding team helps identify your eligible patient panel, prepare consent materials, and manage initial patient outreach to maximize enrollment rates.

Billing Workflow Support

HealthArc's team reviews monthly billing reports for accuracy and completeness before submission, reducing claim denials and documentation gaps.

Compliance Monitoring

The services team monitors program activity to ensure each patient's monthly documentation meets CMS requirements for the applicable CPT code before the billing cycle closes.

Program Performance Reviews

Periodic reviews with your practice administrator or physician champion to assess enrollment rates, revenue performance, and opportunities to expand the program.

Physician Oversight Model

All CCM services delivered through HealthArc operate under the supervising physician's NPI. Physicians set the clinical parameters and approve care plans; HealthArc's coordinators execute outreach and documentation within those parameters. This model satisfies CMS requirements for general supervision.

CCM Services HealthArc's Care Coordination Support

Billing & Reimbursement

CCM CPT Codes, Requirements, and Reimbursement

CMS reimburses CCM services through four primary CPT codes, each tied to specific time thresholds and care complexity requirements. HealthArc’s billing workflow maps each patient’s monthly activity to the correct code automatically.

CPT Code	Description	Time Requirement	Avg. Reimbursement
99490	CCM — first 20 minutes, clinical staff	20 min/month minimum	$62–$64
99439	CCM — each additional 20 minutes	20 min increments beyond 99490	$47–$49
99487	Complex CCM — first 60 minutes, physician/NPP	60 min/month, moderate-high complexity	$130–$135
99491	CCM — 30 minutes personally by physician/NPP	30 min personally by physician or NPP	$82–$85

* Average reimbursement figures are based on national Medicare non-facility rates and may vary by geography, payer, and year. HealthArc recommends verifying current rates via the CMS Physician Fee Schedule.

Documentation Requirements

To bill any CCM code, practices must have on file for each patient:

✓Documented patient consent (verbal or written)
✓An initiating visit within the previous 12 months
✓A comprehensive, current care plan
✓Monthly clinical staff time logs meeting the applicable threshold
✓Evidence of care coordination activity (calls, referrals, medication management)

HealthArc generates and stores all required documentation within the platform, creating an audit-ready record for each billed patient.

Estimate Your CCM Revenue

A practice billing 200 enrolled patients monthly can generate significant recurring revenue — before adding add-on codes or complex CCM patients.

200

Enrolled Patients

60%

Panel Eligibility

$18.7K

Est. Monthly Revenue

$62+

Per Patient / Month

Calculate Your Revenue →

Implementation

How to Implement a CCM Program with HealthArc

Most practices are seeing their first CCM revenue within 60 to 90 days of kickoff. The implementation process is designed to minimize disruption to your existing workflows.

Week 1–2

Discovery and Panel Analysis

HealthArc reviews your patient panel to identify CCM-eligible patients based on diagnosis codes and payer mix. You receive an estimate of your billable population and projected monthly revenue before committing to a full rollout.

Week 2–3

Platform Configuration and EHR Setup

HealthArc configures your practice environment, connects to your EHR for patient data sync, and customizes care plan templates to reflect your preferred clinical workflows and specialty focus.

Week 3–4

Staff Training

Your care coordinators, billing staff, and supervising physicians receive role-specific training on the platform. Training is conducted virtually and typically completed within two to four hours per role.

Month 1–2

Patient Consent and Enrollment

Your team — supported by HealthArc's enrollment specialists if needed — begins outreach to eligible patients to obtain consent and complete initial care plans. HealthArc provides scripts, consent language, and outreach tracking.

Month 2–3

First Billing Cycle

HealthArc generates your first CCM billing report at the end of your first active month. The report is reviewed for completeness before submission. Most practices submit their first claims within 60–90 days of kickoff.

Ongoing

Ongoing Program Management

After launch, HealthArc's platform and optional services team support ongoing monthly outreach, care plan maintenance, time documentation, and billing cycle reporting. Program performance is reviewed quarterly with your team.

Integrations

EHR Integration and Interoperability

HealthArc connects with the EHR systems your practice already uses. Rather than requiring a system replacement, HealthArc pulls patient demographics, diagnosis codes, and medication lists from your existing EHR — and pushes documentation back into the patient record.

Bi-directional Data SyncPatient demographics, diagnoses, and medication lists pulled from your EHR in real time.

Documentation Write-BackCare plan documentation written back to the patient's chart automatically.

HL7 FHIR-Compliant APICertified connections using industry-standard protocols for all major EHR platforms.

Medication ReconciliationMedication data pulled directly from the EHR record for accurate care planning.

Compatible EHR / EMR Platforms

Epic

Athenahealth

eClinicalWorks

Kareo

DrChrono

Modernizing Medicine

NextGen

Allscripts

+ More

No EHR connectivity?HealthArc supports manual patient import via structured data templates. All core platform features function independently of EHR connectivity.

Reporting & Analytics

Reporting and Analytics for CCM Program Performance

HealthArc’s reporting layer gives physicians, care coordinators, and practice administrators the data they need to manage performance proactively — in real time, not just at end-of-month.

Enrollment Dashboard

Active enrolled patients, pending consent, declined, and churned — with trend lines by month.

Monthly Billing Progress

Real-time view of patients at the 20-minute threshold and those at risk of missing the billing cycle.

Time Log Reports

Per-patient breakdown of all logged clinical minutes by activity type, staff member, and date.

CPT Code Distribution

Summary of which codes are being billed across your panel with reimbursement estimates.

Revenue Performance

Month-over-month and year-to-date revenue tracking by location, provider, and patient cohort.

Care Plan Completion

Percentage of enrolled patients with current, complete care plans versus those requiring updates.

Outreach Activity Summary

Volume of monthly patient contacts by coordinator, including completions and non-response rates.

Exportable Reports

All reports exportable in standard formats for integration with practice management and RCM workflows.

Security & Compliance

HIPAA Compliance and Data Security

CCM programs handle sensitive patient health information and are subject to HIPAA Privacy and Security Rule requirements. HealthArc is built to meet those requirements at the platform level, so your practice does not have to build compliance infrastructure independently.

HIPAA-Compliant Infrastructure

All patient data is stored and transmitted in accordance with HIPAA Privacy and Security Rule requirements. HealthArc executes Business Associate Agreements (BAAs) with every practice customer.

AICPA SOC 2 Certified

HealthArc's platform undergoes independent SOC 2 audits covering security, availability, and confidentiality controls — verifiable third-party assurance for your compliance team.

Role-Based Access Controls

Platform access is segmented by role — care coordinators, billing staff, and physicians see only the data and functions relevant to their responsibilities. Access logs are maintained for audit purposes.

Audit-Ready Documentation

Every patient interaction, time log entry, care plan update, and consent record is timestamped and immutable, creating a complete audit trail that supports CMS documentation requirements and payer audits.

Consent Record Management

Patient consent records are stored within the platform and linked to the patient's enrollment record. Consent status is surfaced in the dashboard so your team always knows which patients are eligible to bill.

Data Encryption

Data at rest and in transit is encrypted using industry-standard protocols. HealthArc's infrastructure is designed to protect patient health information across every touchpoint in the care workflow.

HIPAA Compliant AICPA SOC 2 Certified MBE Certified Organization

CCM Program Results

The Chronic Disease Opportunity

Practices using HealthArc for CCM typically see measurable improvement in both program economics and patient engagement within the first two billing cycles.

50%

of U.S. adults have one or more chronic condition — your existing panel likely has hundreds of CCM-eligible patients you're not yet billing for.

7/10

U.S. adult deaths are caused by chronic disease. CCM's care coordination model is designed to reduce acute events and hospitalizations.

100%

Projected increase in adults with chronic disease by 2050. Practices building CCM programs now are positioning for the fastest-growing Medicare segment.

60–90 Days to First RevenuePractices reach full enrollment velocity within 60–90 days of program launch.

40–60% Eligible PanelAverage CCM-eligible panel represents 40–60% of Medicare primary care patients.

$12,000–$18,000+ MonthlyPractices billing 200+ CCM patients generate significant monthly recurring revenue.

Full Audit ReadinessEvery billed patient has a complete, timestamped documentation trail generated by the platform.

Frequently Asked Questions About CCM Software

Answers to the questions practices most commonly ask when evaluating CCM programs and software vendors.

Q1: 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.

Q2: 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.

Q3: 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. [Web team: List confirmed EHR integrations here.] Practices whose EHR does not support API integration can onboard via structured data import.

Q4: 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 — not counting add-on codes or complex CCM patients. HealthArc's revenue calculator can model your specific panel and payer mix.

Q5: 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.

Q6: 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.

Q7: 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

If you’re evaluating CCM software vendors or considering launching a CCM program for the first time, HealthArc offers a guided platform demo tailored to your practice’s specialty, panel size, and current EHR environment.

Schedule a Demo

In a 30-minute demo you will see:

How HealthArc identifies CCM-eligible patients in your panel

The care plan and monthly outreach workflow your coordinators will use

How time is tracked and mapped to CPT codes automatically

What a completed billing report looks like before submission

Revenue projections based on your estimated patient volume and payer mix

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