Generally non-face-to-face services provided to Medicare beneficiaries who have two or more chronic conditions expected to last at least 12 months. CMS recognizes that CCM services are critical components of primary care that promote better health and reduce overall healthcare costs. 

 Provide for the additional care management services patients with metal, behavioral, or psychiatric conditions receive from their primary care team. The primary care team develops a care plan and coordinates treatment across the health care system. 

  A digital health solution that captures and records patient physiologic data outside of a traditional healthcare environment. With this data, the care team can monitor chronic conditions…and intervene in disease management as necessary either in-person or virtually.

  Designed for health care teams to care for patients during their transition from hospitalization to home. The essence of TCM is that a physician or other clinician takes charge of the patient’s care upon discharge to prevent care gaps.