Chronic Care Management

Chronic Care Management Services

"Many providers struggle to balance the 24/7 needs of chronically ill patients within the huge scope of their duties, unable to devote staff to the full-time job of communicating with and creating care plans for these patients outside of face-to-face office visits."
— Michelle Li, MD  |  Internal Medicine

That’s why we’re here.

We make CCM effective for your patients and simple for your practice.
You can do it yourself, or do it effortlessly with Wellbox.

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CCM at a glance

117 million Americans have one or more chronic health conditions.
2/3 of Medicare beneficiaries have 2 or more chronic conditions.

Patients with multiple chronic conditions often visit multiple providers in different organizations, leading to duplication and conflicts in Care Plans.

Medicare began allowing physicians to bill for chronic care management (CCM) in 2015.

CMS specifies that the code must be billed for “non-face-time follow-up care outside the office” each month.

Wellbox Chronic Care Management Services

A dedicated care coordinator acts as an extension of your practice, allowing you to continue running your business the way you always have and generating incremental gross revenue year-on-year.
Our team of trained and registered nurses helps you:

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Provide a complete care coordination cycle.

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Successfully carry out care plans.

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Ensure your Medicare patients are following your recommendations.

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Process all completed enrollment forms.

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Document brief notes in your EHR and allowing you to sign off on the work.

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Stay on top of your patient’s health by receiving calls for all high priority issues.

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Eliminate the need to hire and train new staff thanks to your designated care coordinator.


Meet MACRA and MIPS quality measures.
2017 requirements update

We are an all-inclusive service for reaching your qualified patients, tracking their progress, and billing for the new Chronic Care Management 99490 code. We provide a human touch to CCM. Your patients talk to real people and develop real relationships with them, not robots.

What CCM does for practices

  • It reimburses physician practices for providing ongoing care to Medicare patients with chronic conditions.
  • It helps providers proactively manage patient health rather than only treating disease and illness.
  • It brings a systematic approach to defining and managing a patient’s Care Plan.
  • It organizes care coordination under one provider.

What CCM does for patients

  • It provides patients with a care coordinator that closely monitors their health.
  • It helps patients better understand their Care Plan.
  • It develops meaningful relationships between providers and patients.
  • It offers added care for free for most patients.

Latest CCM Blog Posts

Travel Safety Awareness Month
December is travel safety awareness month. When it comes to older adults, certain precautions must be taken when travelling by plane, train, car or other. Continue reading...

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Care Coordination: Physicians Working as Teams
When a patient goes to the clinic, they often see a nurse and a doctor. However, when they go to the hospital, they might be treated by many nurses and doctors and even...

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Diabetes Awareness Month
November is Diabetes Awareness month. In addition to discussing your patient’s usual health plans, this month, all our Care Coordinators are taking the time to educate your...

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Understanding the Requirements of Code 99490

This code is specific to Chronic Care Management and is the reimbursement of chronic care services for patients with 2 or more chronic conditions.
To be reimbursed for such care, practices must:


Contact each eligible patient every month.


Conduct at least 20 minutes of non face-to-face care.


Establish, implement, revise or monitor a comprehensive care plan.

What’s Involved in CCM


Structured Data Recording

In a Meaningful Use I or II certified EHR.


Care Plan

Patient-centered, accessible and sharable electronically where appropriate.


24/7 Access to Care

Continuity of care with designated care team member and enhanced communication opportunities.


Manage Care

Systematic and documented patient contact, medication reconciliation and care coordination.

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