Tap into a new recurring revenue stream with ChartSpan's Chronic Care Management

Give your patients 24/7 access to care management with ChartSpan; the nation’s largest and most successful Chronic Care Management (CCM) program. ChartSpan’s highly trained care team will reach out each month, telephonically, to your enrolled patients – those with multiple chronic conditions who are most in need of attention and support. We act as an extension of your care coordination team so that your patients with chronic conditions have access to a clinician, 24/7.


Let your staff focus on providing in-person healthcare to patients, and ChartSpan will focus on the rest.

Booking Chronic Care Management services with ChartSpan means taking advantage of full-service solutions covering everything from care plans, communication, and refill assistance while you do what you do best — care for your patients. Other services we provide include:

  • Assistance with medication refills

  • Support in achieving health care goals that you establish

  • Assistance with transportation and mobility needs

  • Assistance with Social Determinants of Health

  • Help in making doctor or specialist appointments

  • Support for caregivers and family members caring for a loved one

  • Assistance in accessing labs, x-rays and tests

  • Continuously building a comprehensive care plan for each patient

How We Help Providers

We provide you with reports that let you know exactly how the program is progressing so you can enjoy the success, without the heavy lifting that CCM programs usually involve. We built our proprietary CCM software to allow our care team to easily track time, document interactions, review patient status and report all progress back to you each month.


New stream of monthly-recurring revenue


Medicare patients remain attributed to your practice


Closed care gaps lead to improved Quality scores


CCM is proven to improve patient outcomes

How We Help Serve Patients

Our 24/7 inbound nurse line is open to patients year-round to address their questions, needs and concerns. We record every patient phone call and make it available at a moment's notice, as well as document and share all activity with providers directly. No matter the report or interaction, you can expect us to document every minute with our Chronic Care Management solutions.


Coordinated care between you and the patient's other providers


Access to our triage nurse line for 24/7 support


CCM patients save $240 per year and see 20% less hospitalization on average


Ensure patients adhere to provider-developed care plans and goals

Shot of female doctor talking with colleagues through a video call with a laptop in the consultation.

Identify and engage eligible Medicare beneficiaries

Medicare beneficiaries must have two chronic conditions to be eligible to participate in Chronic Care Management. Since three out of four people older than 65 have two or more chronic conditions, a large number of your patients should be eligible to participate. Additionally, the Chronic Care Management program requires that each enrolled patient have:

Enrollment Process

Most practices that attempt an in-house CCM program enroll only 10% of their eligible Medicare patients. ChartSpan has learned that the best way to enroll CCM patients is with a group of trained Enrollment Specialists who are experts at engaging patients on the benefits of Medicare’s CCM services and overcoming patient objections. As a result, ChartSpan averages 60%+ patient enrollments. Our team will:

  • Construct Eligible Patient Lists

  • Reconcile Missing CPT Codes and Establish Coinsurance Estimates

  • Obtain Patient Consent with Proven Marketing Strategies

  • Manage the daily churn-in and churn-out of patients

Chronic Care Management Patient Benefits


During our Chronic Care Management enrollment process, our data team will assess your patient data and identify patients who are eligible for CCM according to Medicare requirements. Then, we will send the eligible patient list for final approval.


We then begin by educating patients on our program through voicemails, emails and letters, making multiple attempts to contact each patient so you don't have to. After filling patients in on what to expect, we'll ask for their consent and complete the necessary documentation.


By handling every step of the CCM enrollment process, we enable your team to spend less time focusing on logistics and more time providing patient care. We make it simple to improve your CCM program with higher program participation.


The Workflow Process – End-to-End Support from ChartSpan:

After enrolling your patients into our program, our clinical call center will care for them for the entirety of their time with us, spending 20 minutes every month coordinating preventive care. Our staff will take on tasks like scheduling appointments, requesting records, setting care goals, providing education and making calls to discuss patient updates. ChartSpan handles all moving parts of the CCM process, so you don’t have to. From continuously identifying eligible Medicare enrollees, to closing care gaps through our clinical interactions and improving performance on quality measures, we make CCM effortless for our clients.


* To use our RapidBillAuto technology, your practice must utilize an HL7.

CCM is Available for A Variety of Practice Types

Chronic Care Management can be billed by a variety of practice types. ChartSpan currently provides CCM services to several types of healthcare clientele including primary care, specialty practices, Federal Qualified Health Centers (FQHCs), and Rural Health Clinics (RHCs).

Primary Care

  • Internal Medicine
  • Adult Medicine
  • Family Medicine
  • Geriatric Medicine
  • Pain Management
  • Preventative Medicine

Specialty Practices

  • Rheumatology
  • Nephrology
  • Urology
  • Gastroenterology
  • Endocrinology
  • Cardiology

If You Are an FQHC or RHC

Recognizing that patients who benefit the most from Chronic Care Management are served by providers who qualify for Federal Qualified Health Center (FQHC) or Rural Health Clinic (RHC) status, Medicare has made significant changes to CCM reimbursements in the past two years that can bring big advantages to your practice – and your patients.

CMS increased Chronic Care Management reimbursements from an average of $42 to more than $66 per encounter with a minimum of 20 minutes of care. The CCM billable code for this is G0511.

We’ll Work With Your EHR

The Electronic Health Record (EHR) is a crucial tool for pulling eligible CCM patient lists, pushing out patient comprehensive care plans, and billing each month. ChartSpan is the only CCM vendor to offer No-Charge Data Integrations with any EHR that does not data block.

CCM Frequently Asked Questions (FAQ)

Medicare patients with two or more chronic conditions are some of the most at-risk patients. By providing these patients with a 24/7 care team to help them manage chronic diseases on top of the medical care you provide, you are helping them improve their overall clinical outcomes and quality of life. Patient engagement will improve, and your CCM patients will be provided with a comprehensive care plan that guides them on a path to better health.

Whether you are a primary care office or specialty, your ChartSpan care team will continuously support you in closing gaps in care Doing so drives MIPS and ACO compliance. Practices will also generate a new, additional revenue stream by billing CPT 99490 for Chronic Care Management.

Although health care providers are allowed to provide CCM on their own, it is much more operationally complex than you may expect. The technology and resources required to perform a robust and compliant service are extensive, yet necessary. Outsourcing will provide you with these resources in addition to an entire care team devoted to your program, all hours of the day.

ChartSpan’s CCM services are recognized as the benchmark in the industry:

  • CMS and Medicare compliant patient enrollment services leveraging state-of-the-art telephony infrastructure and analytics
  • Patient enrollment rates averaging 56% of your eligible Medicare beneficiaries
  • The only service provider in the industry with positive Net Patient Churn
  • Extensive quality auditing and record archiving for 10 years
  • Support for practice or cloud-based EHR data access
  • Positive net-patient churn averaging +4% month over month
  • In-house, clinician-staffed call center providing monthly care coordination services and a 24/7 nurse-led hotline
  • Patient satisfaction rating (NPS) of 74.2
  • Dedicated Client Success team accountable for driving value

In addition, ChartSpan is the only CCM company to provide MIPS and Quality Improvement Program services at no additional charge for CCM clients and offers a SaaS-based solution for Annual Wellness Visits.

ChartSpan pricing varies for healthcare organizations and is based on the type of practice and reimbursement rate. The cost for the each patient's membership depends on insurance. Contact the team at ChartSpan for custom pricing.

ChartSpan is capable of integrating with your existing EHR.

No. ChartSpan utilizes our own proprietary CCM software to deliver a streamlined, fully-managed CCM service for your practice.

ChartSpan partners with each practice to deliver CCM to eligible patients. ChartSpan continuously identified eligible patients from the practice EMR, then calls those patients to get their consent to the program. Once the patient is enrolled, ChartSpan reaches out each month to work on care coordination activities that improve the patient's health outcomes. All work is documented in a comprehensive care plan which is then shared with the provider through the EMR.

Why Choose ChartSpan for Chronic Care Management Services?

You can improve patient outcomes and help providers save time and money with CCM solutions from ChartSpan. ChartSpan’s unique approach to Chronic Care Management services ensures full compliance and goes above and beyond to ensure your program is successful. Don’t miss out on this opportunity to provide better care, increase patient satisfaction and receive ongoing reimbursement.

ChartSpan’s turnkey solution handles every step of the program, from identifying eligible patients, and the initial outreach for enrollment, to providing around-the-clock access to nurses. We even support your Quality team in accomplishing your MIPS or QIP measures. We deliver a robust solution that doesn’t interrupt your daily, clinical your workflow, reduces staff workload, and delights your patients.

Contact us to learn more about our services today!


Practices can earn more than $100k per year with 300 enrolled patients

Boost your revenue, provide comprehensive patient care, and drive improved outcomes.