Deliver proactive engagement to recently discharged patients to ensure care plans are being followed and health is improving.

About Transitional Care Management (TCM)

TCM is designed for primary care doctors and specialists, as well as non-qualifying medical practitioners, for care they provide to patients who have been discharged from hospitals or other facilities or institutions as qualified by CMS.

Care Team Involved

  • Physicians (any specialty)
  • Non-physician practitioners (NPPs) who are legally authorized and qualified to provide the services in the State in which they are furnished: Nurse Practitioners, Physician assistants, Clinical nurse specialists, and Certified nurse-midwives
  • Have the option to embed a Peer Advocate or Certintell Health Coach to handle most of the patient-centered care through a shared care plan (Powered by Certintell)
  • An interactive contact must be made with the beneficiary and/or caregiver, as appropriate, within 2 business days following the beneficiary’s discharge to the community setting.

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  • As required by CMS, our solution goes beyond telephonic to cover all of your CCM needs; including asynchronous secure messaging, video calls, and Remote Patient Monitoring (RPM).

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  • You must furnish non-face-to-face services to the beneficiary, unless you determine that they are not medically indicated or needed.

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  • Required face-to-face visit must be furnished under a minimum of direct supervision and is subject to applicable State law, scope of practice, and the Medicare Physician Fee Schedule (PFS) “incident to” rules and regulations.

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