Chronic Care Management (CCM)


What We Offer

Support for patients with two or more chronic conditions—every month.

What ConnectedMD Provides

  • Dedicated care coordinators and health coaches

  • Monthly patient outreach and engagement

  • Care plan reinforcement and goal tracking

  • Medication adherence support

  • Escalation to providers using approved protocols

  • CMS-ready documentation and time tracking

  • Audit-ready reporting and dashboards

What Your Practice Controls

  • Clinical oversight and medical decision-making

  • Care plan approval

  • Billing and claims submission

  • The patient relationship

1. Onboard

Comprehensive training equips you and your entire team to confidently launch the program.

2. Identify & Enroll

We identify eligible patients, you approve the eligibility list, and we enroll them in the program.

3. Engage

Each month, we connect with enrolled patients to encourage active participation in their care.

4. Support

We support patients at your practice in achieving positive health outcomes.

5. Measure

We continuously track quality and performance metrics while helping ensure ongoing compliance.

6. Billing

You review and bill, and then we receive payment from you.


Frequently Asked Questions (FAQ)

  • ConnectedMD provides a comprehensive Chronic Care Management service that functions as a virtual extension of the practice.

    Services include monthly care coordination, symptom monitoring, medication support, and personalized care plans based on each patient’s chronic conditions and lifestyle needs.

    ConnectedMD also manages remote device delivery and training for eligible patients, provides ongoing remote monitoring, and responds to triggered alerts for urgent health concerns.

    Patients receive 24/7 access to their assigned health coach for guidance, triage, and support. Medify documents all interactions and minutes required for CCM billing, ensuring practices capture eligible reimbursement without additional staff burden.

  • ConnectedMD stores all remote physiological monitoring device data in its secure, HIPAA-compliant data servers. A ConnectedMD health coach responds immediately to any alerts triggered by a reading, and follows protocol to confirm the reading and facilitate emergency care as needed.

    The patient’s assigned health coach also reviews the biometric data trends to inform the patient’s ongoing treatment plan and coaching sessions. The data-driven insights are placed directly into the patient’s medical record in the practice’s EMR so the patient’s physician can use the data for in-office discussions.

    ConnectedMD’s full-service RPM and CCM approach allows the medical provider to benefit from remote monitoring without overwhelming the staff with data to track and interpret directly.

  • ConnectedMD does not charge any upfront cost for its RPM + CCM services.

    ConnectedMD manages all related RCM and covers all costs from the revenue generated from billable encounters (Medicare CPT codes).

    As a result, ConnectedMD clients tend to start receiving incremental revenue from ConnectedMD’s services within 120 days of launching ConnectedMD’s services.

    ConnectedMD does not get paid until after its clients begin receiving revenue from ConnectedMD’s billable encounters.


“Their attention to detail and commitment to quality truly stood out. We’ve already recommended them to others.”

– Former Customer