Checklist for Starting a Chronic Care Management Program in 2027

Updated October 2026

Thinking about starting a chronic care management (CCM) program? You're in good company, and the timing has never mattered more. Remote care has changed a lot in the last few years, but institutional support from CMS, state Medicaid, and a growing number of private insurers has remained a reliable constant. But as support for and adoption of programs like CCM has grown, so has oversight. Organizations looking to start scalable, reimbursable CCM programs in 2027 can benefit from years of operational best practices and technology innovations to implement successful and compliant care management right from the start.

This guide walks you through how to start a CCM program in this new landscape, step by step. You'll understand the key decisions to make, how to tailor a program to the needs of your organization, and how to build a checklist your team can use to launch a program that serves patients and your team.

How to start a CCM program: the short answer

Chronic care management (CCM) is a Medicare service that pays practices for non-face-to-face care management of patients with two or more chronic conditions expected to last at least 12 months.

For providers, chronic care management creates a meaningful, recurring source of added revenue; enables more comprehensive patient care; builds patient loyalty and engagement; and helps preserve in-office visits for patients who need them.

For patients, CCM improves access to the care team and helpful resources; enables patients to better manage their medications and symptoms; saves money on hospitalizations and costlier, reactive treatments; and encourages a more active role in their health.

Starting a CCM program comes down to 6 steps:

1. Identify your patient cohort and choose CCM, APCM or both

2. Confirm you can meet compliance requirements

3. Choose your staffing model and technology

4. Build care protocols and care plans

5. Enroll, engage, and retain patients

6. Bill, measure, and scale

The opportunity is large because so few eligible patients get the service. About 1.5 million Medicare patients received CCM under CPT 99490 in 2024, according to our analysis of the latest CMS data. Yet nearly 25 million Medicare fee-for-service beneficiaries were eligible for CCM that year, and only 6.6% had a CCM claim, according to HHS. For most practices, the eligible patients are already on the panel. A growing body of clinical evidence also shows CCM has measurable benefits or patients and the system, with significant clinical improvements for patients with a wide range of chronic conditions.

This checklist draws on Prevounce's years of experience supporting hundreds of CCM programs nationwide. Each step includes the essential decisions to guide the creation of your program and a checklist you can work through with your team.

What's changing for CCM in 2027

CCM itself was largely untouched in the CY 2026 rule, and the CY 2027 proposals focus mainly on remote monitoring. CMS proposed limiting RPM and RTM treatment management to a practice's own clinical staff and requiring an initiating visit before monitoring starts, a requirement CCM already has. If your CCM program will include remote monitoring in conjunction with care management to maximize the clinical and financial benefits to your practice, plan your staffing model with that in mind.

For the full breakdown on what is changing for CCM in 2027, register for our webinar "Understanding Medicare's 2027 Changes to Remote Care Management" where Daniel Tashnek, JD, will cover all of the major changes included in the PFS Final Rule.

Step 1: Identify your patient cohort and choose CCM, APCM, or both

Start with a defined pilot group, not your whole eligible panel. A pilot of one physician panel or a few hundred patients lets you test workflows, staffing, and patient messaging before you scale. Plan capacity around realistic enrollment and not the total eligible patients. While each practice is different, a first-year enrollment of 10-25% of eligible patients is a good target for practices just getting started. For help determining which patients qualify, see our CCM patient eligibility quick guide.

Checklist for identifying your patient cohort and choosing a care management program:

• Run an eligibility report: Medicare patients with two or more chronic conditions expected to last 12+ months.
• Identify your most common conditions (for example, hypertension, diabetes, COPD, heart failure).
• Decide which conditions your care team is best equipped to manage.
• Choose your pilot cohort: one provider panel, one location, or one risk tier.
• Decide whether you'll focus on high-risk patients first or include moderate- and low-risk patients.
• Outline what acute events might trigger patient enrollment into care management. 
• Decide whether you'll be using APCM, CCM, or both, and whether you want to add remote patient monitoring (RPM) for some patients, and for which conditions.
• Set a pilot enrollment target and a date to review results.

This is also the moment to decide which program fits, whether that's traditional CCM, or advanced primary care management (APCM). Since 2025, primary care providers can bill APCM to provide care management services based on practice capabilities and patient complexity rather than dedicated care time each month. CCM remains the time-based option and is available to specialists as well as primary care. The two can't be billed for the same patient in the same month so it is important to either choose one program to implement, or to define clear criteria for who is enrolled in each program before enrolling patients.

For a more in depth explanation of how these programs compare, and how they can be used together to benefit patients watch our on-demand webinar "CCM and APCM: How Remote Care Programs Are Staying Ahead".

Step 2: Confirm you can meet compliance requirements

Before you enroll a single patient, make sure your practice can meet Medicare's CCM requirements every month. Compliance gaps at the outset will become major sources of audit risk as the program scales.

Checklist for meeting CCM compliance requirements:

• Patient cohorts have two or more chronic conditions expected to last at least 12 months (or until death) that place them at significant risk of death, acute exacerbation or decompensation, or functional decline.
• New patients, or patients not seen within the past year, receive an initiating visit before CCM begins.
• You can obtain and document consent, including telling patients about cost-sharing and their right to stop.
• Offer 24/7 access to physicians or other qualified healthcare team members. This can be accomplished through the telephone or telehealth modalities such as a secure internet portal or email.
• Use a certified EHR system.
• Each patient has a designated care team member and an electronic care plan, with a copy provided to the patient.

CMS summarizes these requirements in its Chronic Care Management Services booklet. For a complete reference, see our chronic care management guide.

Step 3: Choose your staffing model and technology

Staffing is the decision that most often makes or breaks a CCM program. Many practices underestimate the ongoing time it takes to call patients, update care plans, coordinate with specialists, and document every minute.

You have three main options for CCM staffing:

Whichever model you choose, documentation has to hold up to an audit. Every minute of care management time and every care plan update must be recorded, whether in your EHR or a dedicated platform that tracks time automatically.

• Estimate monthly care management hours for your pilot cohort.
• Set a target caseload per care manager.
• Designate a program owner responsible for enrollment, quality, and billing.
• Decide on in-house, outsourced, or hybrid staffing.
• Choose the level of technology needed to implement your ongoing care management services.
  • Some programs use their EHR to deliver care management services.
  • Many programs opt for purpose-built remote care management software that streamlines care activities,  reduces staff workload, and automates compliant documentation and billing.
• If you outsource, confirm how the partner documents time, escalates issues, and stays compliant.

If you're weighing outside support, our guide to remote care management services explains how outsourced and hybrid models work.

Step 4: Build care protocols and care plans

Care protocols make your program consistent. They tell care managers what to ask, what to track, and when to escalate to a clinician. For each condition in your pilot, draft a protocol and a matching care plan outline, including escalation triggers: specific readings or symptoms that prompt an immediate notification to the practitioner.

• Draft a care protocol and escalation triggers for each target condition.
• Build care plan templates covering patient goals, barriers (including social determinants of health), medications, and community resources.
• Decide which metrics to track for each condition (for example, blood pressure, blood glucose, weight).
• Have a supervising physician review and approve the protocols.

Step 5: Enroll, engage, and retain patients

Enrollment works best when patients hear about CCM from someone they trust, ideally their own physician. The annual wellness visit is a natural moment to introduce it.

Be upfront about cost. Medicare requires a 20% coinsurance for CCM, and because the service is mostly non-face-to-face, patients often don't understand why they're being billed. Explaining the cost early, alongside the value of fewer ER visits and hospital stays, prevents disenrollment after the first statement arrives.

After enrollment, retention depends on relationship. Patients stay when they talk with the same care manager, see progress on goals they helped set, and feel the program is worth their time.

• Write a short patient handout and script the enrollment conversation, including a response to cost objections.
• Build CCM into your annual wellness visit workflow.
• Obtain verbal or written consent and document it in the medical record.
• Create each patient's care plan and give them a copy.
• Set SMART goals (specific, measurable, attainable, relevant, timely) with each patient.
• Assign each patient a consistent care manager, and use motivational interviewing to support behavior change.
• Track who disenrolls and why.

Step 6: Bill, measure, and scale

CCM is billed once per calendar month, based on the time and type of care management provided. For codes, time thresholds, and current rates, see our CCM billing guide and code guides for CPT 99490 and CPT 99439.

Track results from the first month, and decide in advance what will trigger expansion beyond your pilot. Programs that don't measure churn often look healthier than they are.

• Reconcile documented time against claims and audit a sample of records each month.
• Confirm which services can be billed together for patients also in RPM.
• Review results with providers and staff quarterly.
• Expand in stages: add a provider panel, location, or condition at a time.

How long does it take to start a CCM program?

Most of the work happens before the first patient enrolls. Launch time depends mainly on your staffing model: outsourcing or a hybrid model is usually faster than hiring and training an in-house team. 

Ready to start your CCM program?

Prevounce helps practices, health systems, and FQHCs launch and grow chronic care management programs with CCM software, care management services, and billing and compliance expertise. Whether you staff in-house, outsource, or use a hybrid model, we can help you plan your pilot and get to your first billed month. To learn more, schedule a free consultation. 

Frequently asked questions about starting a CCM program

How many patients do I need to start a CCM program?

There's no minimum. Many practices start with a pilot of one provider's panel or a few hundred eligible patients, then expand once workflows and staffing are proven.

Can a CCM program be outsourced in 2027?

Under current rules, practices can work with a care management partner whose staff provide CCM under the billing practitioner's general supervision. The CY 2027 proposed restrictions on vendor staff targeted remote monitoring, not CCM.

Can I bill CCM and APCM for the same patient?

Generally not in the same month. Practices that offer both typically assign each patient to one program. Download our APCM billing guide to review all of the specific rules.

Is verbal consent enough for CCM?

Yes. Consent can be verbal or written, but it must be documented in the patient's medical record, along with confirmation that the patient was told about cost-sharing and their right to stop.

What enrollment rate is realistic for a new CCM program?

No program enrolls every eligible patient, and each practice's situation is unique, but a first-year enrollment of 10-25% of eligible patients is a good target for practices just getting started. Plan staffing around realistic enrollment, and track retention as closely as new enrollments.

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Disclaimer

Health economic and reimbursement information provided by Prevounce is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules, and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice.

Prevounce encourages providers to submit accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit appropriate codes, charges, and modifiers for services rendered. It is also always the provider’s responsibility to understand and comply with Medicare national coverage determinations (NCD), Medicare local coverage determinations (LCD), and any other coverage requirements established by relevant payers which can be updated frequently.

Prevounce recommends that you consult with your payers, reimbursement specialists, and/or legal counsel regarding coding, coverage, and reimbursement matters.

Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding, or site of service requirements.

The coding options listed here are commonly used codes and are not intended to be an all- inclusive list. We recommend consulting your relevant manuals for appropriate coding options.

The Health Care Provider (HCP) is solely responsible for selecting the site of service and treatment modalities appropriate for the patient based on medically appropriate needs of that patient and the independent medical judgement of the HCP.