Chronic Care Management

Chronic care that continues
between visits

HealthViewX finds eligible patients, builds and maintains their care plans, runs a check-in every month, and captures every billable minute so your team delivers consistent chronic care management, and the recurring Medicare revenue that comes with it.

Chronic Care Management — Care Worklist
Billing month: August 2026
65%
Enrollment conversion
PatientChronic ConditionsEnrollmentCare PlanThis MonthLast ContactCPT Code
Grace Robins
HTN, A-Fib
EnrolledActive
18:40
Aug 12
99490
Brandon Kelly
COPD, CHF
EnrolledActive
14:10
Aug 09
99490
Denise Scott
Diabetes, CKD
PendingReview
6:05
Aug 03
Marco Tran
HTN, CKD
EnrolledActive
22:30
Aug 14
99439
✦ AI Eligibility Detection
128
patients surfaced this week — 3+ chronic conditions, auto-identified
~$900
Medicare savings per patient annually
65%
Enrollment conversion
Proven Outcomes

A CCM program that runs itself

More patients enrolled, more minutes captured, more revenue with less manual work.

65%
Enrollment Conversion From Total Population
Automatically surface and enroll patients with 2+ chronic conditions.
5%
Fewer Hospitalizations & ED Visits
Proactive monthly check-ins catch deterioration before it escalates.
20%
Improvement in Medication Adherence
Automated refill reminders and adherence tracking between visits.
~$900
Annual Medicare Savings Per Patient
Coordinated care plans cut duplicate tests and avoidable utilization.
Why Health Systems Choose HealthViewX

Better outcomes, sustainable revenue

Everything a compliant, scalable CCM program needs in one place.

Effortless Enrollment

Auto-identify and enroll patients with two or more chronic conditions.

Living Care Plans

Personalized, always-current plans mapped to each patient's conditions.

Automatic Time Tracking

Every billable minute logged for clean, audit-ready claims.

Consistent Monthly Outreach

Care team and AI agents reach every patient, every month.

New Recurring Revenue

Capture the Medicare CCM reimbursement you're leaving on the table.

Better Outcomes

Proactive management reduces care gaps, ER visits, and readmissions.

Less Admin Burden

Documentation and billing prep handled automatically.

More Patient Time

Less busywork for staff, more meaningful contact with patients.

Schedule Demo
Product Capabilities

One system for the whole CCM cycle

Everything your team needs to enroll, engage, document, and bill powered by AI scribe and call-centre agents.

01 · IDENTIFY

Eligible patient finder

Surface patients with 2+ chronic conditions straight from your EMR.

02 · ENROLL

Guided consent & Enrollment

Capture verbal or written consent and enroll patients in minutes.

03 · PLAN

Personalized care plans

Condition-specific plans that update as the patient's needs change.

04 · ENGAGE

Monthly patient outreach

Care coordinators and AI agents check in with every patient, every month.

05 · TRACK
Time captured per task

Automatic time & task capture

Every minute and interaction logged toward the right CPT code.

06 · BILL & REPORT
99490

Claim-ready documentation

Generate CPT 99490/99439/99487 claims and program reports on demand.

Reimbursement

Medicare CCM reimbursement, built in

CCM pays recurring monthly revenue for coordinating care. HealthViewX tracks the time and assigns the right code — standard, complex, physician-provided, or FQHC.

ServiceRequirementFrequencyReimbursement
CPT 99490
CCM, initial
Standard
20 min, clinical staffPer month~$62
CPT 99439
CCM, each additional
Standard
Additional 20 minAdd-on~$47
CPT 99491
CCM, initial
Physician / QHP
30 min, physician / QHPPer month~$83
CPT 99437
CCM, each additional
Physician / QHP
Additional 30 minAdd-on~$59
CPT 99487
Complex CCM, initial
Complex
60 min, clinical staffPer month~$132
CPT 99489
Complex CCM, each additional
Complex
Additional 30 minAdd-on~$70
CPT G0511
CCM for FQHCs / RHCs
FQHC / RHC
Per calendar monthPer month~$70
Interoperability

Works with your existing systems

HealthViewX, HealthBridge, connects seamlessly with your EMR/EHR, PHM, and third-party systems for a true all-in-one, value-based care experience.

Epic
Allscripts
NextGen
eClinicalWorks
MEDITECH
Centricity
AdvancedMD
CareCloud
Practice Fusion
Cerner
✓ Bi-directional Sync
✓ Real-time Updates
✓ Patient Demographics
✓ Clinical Data
✓ Orders & Results
✓ Scheduling
Built for Enterprise Healthcare
HIPAA
GDPR
AICPA SOC
EscrowTech Secured
ONC-Certified Health IT
Drummond Certified
Trusted by Leading Healthcare Organizations
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