Humhealth provides best-in-class easy to use chronic care management services for both healthcare organizations and the patients they serve. Our platform ensures the successful completion of all activities ranging from identifying and enrolling the right patients, all the way to being reimbursed after the end of a care cycle.

For clinicians, it allows them to add other care team members, engage in two-way communication, assess patients remotely, create and personalize care plans, monitor the patient’s condition, and not worry about tracking time for all relevant chronic care management services provided.

For patients, it ensures that they stay connected with the rest of their care team, receive instructions and educational materials remotely, and track their lifestyle which includes adhering to the right diet, nutrition and medications.

Any reimbursable chronic care management services or activities are automatically captured by the timer that is built into our platform. This includes the time spent by clinicians and their team defining a chronic care management plan and conducting non-face-to-face follow-up calls every month.

Web App Features


We have an amazing array of web and mobile app features that are synchronized to account for usage in both types of devices. Regardless of where the care team and the patient are situated, they always have access to our platform as it’s compatible with all the major operating systems out there including PC, macOS, Android and iOS.


Humhealth also provides a seamless experience when it comes to picking out the right devices to match its software for providing chronic care management services. Different pricing options are available depending on the remote patient monitoring package selected to measure the relevant vital sign.


  • Personalized care plan for each patient

    Personalized care plan for each patient

  • Tracking Physician and Clinician time separately and Utilizing Optimal CPT code for billing

    Tracking Physician and Clinician time separately and Utilizing Optimal CPT code for billing

  • Two way communication with patient through Text Message

    Two way communication with patient through Text Message

  • Continuity of Care Document Upload and EMR Integration

    Continuity of Care Document Upload and EMR Integration

  • Feature to initiate video Call

    Feature to initiate Video Call

  • VOIP Integration with multiple vendors

    VOIP Integration with multiple vendors

  • HIPAA compliant Fax integration

    HIPAA compliant Fax integration

  • Synchronization of patient self-assessment data from Mobile app

    Synchronization of patient self-assessment data from Mobile app

  • Automated Time Tracker

    Automated Time Tracker

  • Define Care Team Members

    Define Care Team Members

  • Comprehensive Monthly Service Summary

    Comprehensive Monthly Service Summary

  • Comprehensive Scheduling Feature

    Comprehensive Scheduling Feature

  • CCM Current Month Status Dashboard

    CCM Current Month Status Dashboard

  • Customize Questionnaire for tracking Goals, Lifestyle Recommendations and Medications

    Customize Questionnaire for tracking Goals, Lifestyle Recommendations and Medications

  • Disease-specific questionnaire for common chronic diseases

    Disease-specific questionnaire for common chronic diseases

  • Questionnaire Configuration at facility and patient levels

    Questionnaire Configuration at facility and patient levels

Mobile App Features

  • Patient and Physician mobile app

    Patient and Physician mobile app

  • 24/7 access to care plan by patient

    24/7 access to care plan by patient

  • OTC Medication

    OTC Medication

  • Physical activity tracking

    Physical activity tracking

  • Record symptoms

    Record symptoms

Humhealth Mobile app
  • View the training session recording

    View the training session recording

  • View newsletter and educational material

    View newsletter and educational material

  • Calorie tracker

    Calorie tracker

  • Feature to attend a Video call

    Feature to attend a Video call

  • View call summary

    View call summary

CCM Workflow

  • workflow 1

    1

    Identify Eligible Chronic Patients

    Clinicians identify eligible patients with chronic diseases using his/her patient list or from Electronic Medical Records (EMR).
  • workflow 2

    2

    Enrol The Patient

    On identifying the patients with two or more chronic conditions, the clinicians will enrol the eligible patients for Chronic Care Management program following the patient’s consent.
  • workflow 3

    3

    Define A Care Plan

    Based on the patient’s health records, the Clinicians will formulate a suitable care plan. When a Clinician defines a care plan for a Patient, the automated timer will run to capture the time spent on providing CCM service and thus helps to keep track of chronic care records.
  • workflow 4

    4

    Monthly CCM

    The Clinician will have a monthly follow up call with the Patient to provide CCM service.
  • workflow 5

    5

    Track Time

    During the non-face-to-face interaction by a Clinician with the Patient, the automated timer will run to record the time spent on calling a patient.
  • workflow 6

    6

    Timely Reimbursement

    Most would accept that the tedious part of CCM is getting a reimbursement. Humhealth’s CCM platform tracks and records everything from calls and interactions, bills and generates simple billing reports. Then, all you have to do is to review and forward the reports to the biller.

Billing Codes


We cover an extensive list of chronic care management billing codes that make up both complex and non-complex chronic care for hospitals, private practices, rural health clinics and federally qualified health centers.

Humhealth is unmatched in its field when it comes to pricing transparency. Our plans are flexible, we are clear on the different options available to you based on your budget. We understand that doing research on pricing takes up a lot of time, and thus have made everything transparent when it comes to browsing different price options to figure out the right fit. Our goal is to provide a delightful onboarding experience so your team and your patients can start realizing the benefits of a chronic care program.

At a time when the world shifts to value-based remote care, we are on standby to support any healthcare organization set up and run their chronic care management operations. Chronic care fits well with other types of reimbursable [programs mentioned in our website. If you have any questions, please do email us or use the chat feature. If you are ready to get started, please sign up for a demo.


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  • CPT 99490

  • Chronic care management services provided by clinical staff and directed by a physician or other qualified health care professional (Non- Complex)
  • Duration 20 minutes
  • $42.84

    Average Reimbursement
  • CPT 99439

  • Add-on code – first increment (non-complex CCM)
  • Duration 20 minutes
  • $38

    Average Reimbursement
  • CPT 99439

  • Add-on code – second increment (non-complex CCM)
  • Duration 20 minutes
  • $38

    Average Reimbursement
  • CPT 99491

  • Chronic care management services, provided personally by a physician or other qualified health care professional
  • Duration 30 minutes
  • $84

    Average Reimbursement
  • CPT 99487

  • Complex Chronic care management services provided by clinical staff and directed by a physician or other qualified health care professional
  • Duration 60 minutes
  • $94.68

    Average Reimbursement
  • CPT 99489

  • Add-on code for Complex CCM Service
  • Duration 30 minutes
  • $47.16

    Average Reimbursement
  • CPT G0511

  • CCM Service for Rural Health Clinic (or) Federally Qualified Health Center
  • Duration 20 minutes
  • $67.03

    Average Reimbursement

FAQ

Medicare patients with at least two or more chronic diseases that are expected to be present for at least 12 months or until death of the patient.

Advance consent for CCM services may be verbal or written. If the consent is verbal, there should be documentation in the electronic health record reflecting this.

There are a wide range of services that can be provided under CCM for Medicare beneficiaries with multiple chronic conditions.
  • Care management and transitional care management services
  • Communicating with the Medicare beneficiary in person, by phone, or electronically for care coordination
  • Community resource referral and linkage
  • Coordinating community and social support service
  • Medication management
  • Symptom management
  • Preventive health counselling
  • Health coaching

Regular CCM covers 20 minutes of clinical staff time per month for ongoing oversight, management, and care planning.Complex CCM places the patient at significant risk of death. Minimum of 60 minutes of Clinical staff time is required with substantial revision of care planning and moderate to high complexity in medical decision making. All CCM services (regular and complex) must be provided under the supervision of a physician or non-physician provider (nurse practitioner or physician assistant).

The care plan should include the details of the following elements:
  • Problem list detailing the chronic conditions the patient suffers from
  • Expected outcome and the likely course of the disease
  • Measurable treatment goals
  • Symptom management
  • Planned interventions through regular follow-ups and vital data collection from patient
  • Medication management depending on any concerns/reactions/improvement reported by the patient
  • Care coordination plan between care provider and patient’s caregiver such as family/nurse/community housing etc.
  • Requirements for periodic review and revision of the care plan is required.

Yes. CMS requires the care provider to share the care plan with the patient in a written or electronic format.

CMS has stated the transmission has to be electronic. Facsimile transmission does not satisfy the requirement.

During any given month, a Medicare beneficiary can receive CCM or complex CCM, but NOT both. Only one qualified provider entity can bill for CCM services each month.

The CCM service period is one calendar month. Practitioners may report CCM at the conclusion of the service period, or after completion of the minimum required service time.

Chronic care management services can be billed if the beneficiary dies during the service period, as long as at least 20 minutes of qualifying services were furnished during that calendar month and all other billing requirements are met.

Physicians and Non-Physicians can claim reimbursement by billing for CCM CPT Codes. CCM code is most likely to be billed by primary care physicians. However, specialists, nurse practitioners, physician assistants, clinical nurse can also bill CCM.