Care ManagementSoftware That KeepsEvery Team on OnePlan
Most of care management happens with no patient in the room — the call, the medication check, the chase after a discharge. It is also one of the few places in healthcare where that invisible work is paid for directly. It pays on a plan, an owner and documented time.
Unified CoreOne plan, not four
A single care plan every team writes into, rather than a copy per program that drifts within a month.
AccountabilityEvery task has a name on it
Goals and interventions carry an owner and a due date, so “the team is following up” becomes a person and a date.
Ledger FidelityTime that counts
Care management minutes captured against the right patient, program and month while the work is happening.
Rule ShieldConflicts caught before the claim
One patient, one care management month, one billing practitioner — enforced in the record, not found in an audit.
The product
What Elixir Care Management Software Actually Does
Care management breaks in the gap between the plan and the work. Elixir closes it by keeping both in the same record: the plan, the tasks, the minutes, the outreach and the claim are one set of data on the Salesforce platform, not four systems reconciled at month end.
One shared care plan
Goals, objectives and interventions as real objects with owners, due dates and status at every level, with barriers drawn from the patient’s social determinants record. Detailed on our care plan software page.
Active Care Mapping
A contemporaneous time ledger
Minutes recorded as the work happens, by the person who did it, against the patient and the enrolled program. Time reconstructed at month end is the weakest evidence in an audit and the main reason organizations under-bill.
Audit-Grade Trace
Thresholds visible during the month
How close each enrolled patient is to this month’s threshold, while there is still time in the month to act on it. The care manager should not have to remember which program applies.
Proactive Tracking
Clocks that start from the event
Admission, discharge and transfer feeds, plan notifications and referrals land as events against the patient, so a transitional care window starts on the discharge date rather than when the fax is opened.
ADT Event Sync
Consent captured once
Consent, the care plan, the time entries and the practitioner of record all attached to the care management month, so an audit response is a query rather than a project.
Single-Click Binder
A collaborative care registry
A live list of every patient in the program with current score, last contact, trajectory and time in treatment — so the weekly psychiatric caseload review is a working session, not a spreadsheet.
CoCM Registry
Panel and caseload views
Who has had no contact, who has an open goal, who is drifting — and assigned caseload against contact actually delivered, per care manager, this month.
Caseload Balancing
Billing conflict detection
A patient’s care management month is a single object with one program and one billing practitioner. A second claim against it is a conflict raised before submission.
Pre-Claim Guardrail
Programs as configuration
Eligibility, required services, cadence, documentation and billing shape are configured, not coded. Adding a state Medicaid program or absorbing a rule change is a data change.
Metadata-Driven Engine
Built on Salesforce, so the care plan, the outreach, the scheduling and the claim are the same record. Related: Care Coordination for work that crosses an organizational boundary, Value-Based Care for the measures that score the result, and Contact Center for the outreach.
The commercial case
Chronic Care Management Billing: Getting Paid for the Work Between Visits
Nearly all of this pays on documented time against a monthly threshold, which makes the record the revenue. Two features of the rules matter more than the rest: the work may be furnished under general supervision, so a centralized care team is viable at all — and almost nobody is using the codes. Chronic care management reaches a low single-digit percentage of eligible Medicare patients; collaborative care reaches well under one per cent of beneficiaries with a behavioral health condition.
| Program family | Typical codes | What Medicare requires |
|---|---|---|
| Chronic care management | 99490, 99439, 99491, 99437 | Two or more chronic conditions expected to last a year or until death. 20 minutes of clinical staff time in the month, or 30 of the practitioner’s own; a comprehensive care plan; patient consent; certified EHR technology |
| Complex chronic care | 99487, 99489 | 60 minutes of clinical staff time and moderate or high complexity medical decision-making — the complexity is a clinical judgment, not a time bracket |
| Principal care management | 99424–99427 | A single high-risk condition expected to last at least three months, with a disease-specific care plan rather than a comprehensive one. The route in for specialists |
| Transitional care | 99495, 99496 | Contact within two business days of a discharge, then a face-to-face visit within fourteen days, or within seven for the higher-complexity code. The clock starts on the discharge day |
| Behavioral health integration | 99484, G0323 | 20 minutes in the month, a validated rating scale, a care plan and systematic follow-up |
| Collaborative care | 99492, 99493, 99494, G2214 | 70 minutes in the first month and 60 thereafter, a patient registry, and weekly caseload review with a psychiatric consultant |
| Advanced primary care | G0556–G0558 | No time threshold at all. Ten service elements must be in place, including 24/7 access, an electronic care plan and population-level management of the attributed panel |
| Community health integration | G0019, G0022 | Unmet social needs interfering with a diagnosis or treatment plan. 60 minutes by auxiliary personnel incident to the practitioner, under general supervision |
| Principal illness navigation | G0023, G0024, G0140, G0146 | Navigating a serious, high-risk illness. 60 minutes by navigators or certified peer support specialists under general supervision |
| Caregiver training | 96202, 96203, 97550–97552 | Training the caregiver in the techniques the patient’s care depends on. The patient does not have to be present — which is the point, and the thing most organizations do not realize is payable |
Thresholds reflect the calendar year 2026 Physician Fee Schedule final rule; general supervision for designated care management sits at 42 CFR 410.26(b)(5). Nothing on this page is billing advice, and we would encourage you to verify every requirement against the published rule rather than a vendor’s summary, ours included.
The shift
Advanced Primary Care Management: Care Management Without the Stopwatch
The most interesting thing Medicare has done here recently is to stop counting minutes. These codes pay monthly for an attributed panel and ask instead whether a defined set of capabilities genuinely exists — which makes them a better fit for organizations whose care management is real but whose minute capture is patchy.
What changesA capability test, not a time test
Payment is monthly, per attributed patient, across three clinical levels.- No minimum minutes per patient per month to track.
- No stopwatches running during patient calls.
- Cannot be billed in the same month as CCM, PCM, TCM, BHI or CoCM for the same patient.
What you have to haveTen service elements, several of them structural
- 24/7 access to care team members with EHR access.
- Continuity of care with a designated practitioner.
- Comprehensive electronic care plan available to the patient and other care team members.
- Care management for transitions of care.
- Ongoing population-level management of the panel.
What Elixir contributesThe elements as working features, not attestations
- The shared care plan that survives the encounter.
- Automated transitional care tracking off ADT feeds.
- Population-level panel views for gap closure.
- Attribution ledger linked to the patient record.
- Billing conflict rules that stop a CCM claim going out in an APCM month.
Levels, required elements and the interaction with the time-based families are set by CMS and were revised again for 2026. Elixir holds program definitions as configuration, so a rule change is a data change.
Transitions
Transitional Care Management: the Thirty Days After a Discharge
The most time-bound care management work, and the most frequently lost. Three clocks start at once, they start on the day of discharge rather than the day you hear about it, and two of them are short.
Day 0The discharge happens, whether or not you know
The clock starts on the calendar day the patient leaves an inpatient hospital, observation, SNF, partial hospitalization or rehab stay. TCM cannot be billed if you do not know the discharge happened until day four. Elixir consumes ADT and event notification feeds directly onto the patient record, so the case opens and the window starts the day the patient leaves.
2 business daysInteractive contact, and a documented attempt counts
Telephone, email or face-to-face. Clinical staff under general supervision can make it. Two failed attempts qualify if made within the two business days and documented contemporaneously, with continuing effort thereafter. Elixir logs the attempt, the channel and the timestamp against the transitional care episode.
7 or 14 daysThe face-to-face visit, inside the window the complexity sets
Within 14 calendar days of discharge for moderate medical decision-making (99495), within 7 for high complexity (99496). Must be delivered by a physician or qualifying non-physician practitioner. Elixir links the post-discharge visit scheduling to the TCM episode so the open window is visible to scheduling staff.
The missEscalation while the window is still open
If day two passes without contact or day twelve without a scheduled visit, the episode flags for supervisor intervention. If the face-to-face is missed, the work already done converts where eligible to a general care management month, rather than being written off as lost time.
For the integration work that brings discharge notifications in, see Integrations and our guide to ADT feeds.
Compliance
Care Management Billing Compliance: Where the Audits Actually Land
Federal audits of chronic care management have found overpayments in the millions. Almost all of it comes from two mistakes, and both are structural rather than clinical.
Mistake 1The same month, billed twice.
CMS allows only one practitioner to bill chronic care management for a patient in a given calendar month. When a primary care clinic and a cardiologist each run a care management program without knowing about the other, one of the claims is an overpayment.
Frequent Audit Finding
- Mistake 2
Overlapping services.
CCM cannot be billed during the 30-day post-discharge period of Transitional Care Management by the same practitioner; collaborative care, complex chronic care, remote patient monitoring and the new APCM codes each have their own mutual-exclusion rules.
Structural Rule Friction
The Elixir FixWhat Elixir does about it.
Because a patient’s care management month is a single object in Elixir, the platform enforces these rules before claim submission: a second enrollment in the same month requires explicit override, a TCM episode suppresses CCM claims across the 30-day window, and time entries can belong to only one program at once.
Automated Enforcement
OIG report A-07-21-06088 (November 2023) examined Medicare payments for chronic care management services and found that CMS paid millions in improper payments for CCM claims that did not comply with Medicare requirements, principally through duplicate monthly claims and claims overlapping with other services.
Straight answers
What We Will Not Claim About Care Management Software
So why do it? Because it is now paid for directly.
Under fee-for-service, phone calls with patients, coordination with pharmacies and follow-ups after discharge were uncompensated overhead. Under the care management code families, they are reimbursable encounters with defined billing rules. Even without an active value-based contract, an organization that delivers this care can bill for it legally and profitably.
And under value-based contracts, care management is the primary mechanism for closing quality gaps, preventing avoidable readmissions, and keeping attributed populations healthy enough to stay out of the hospital. The codes provide the immediate cash flow to sustain teams that would otherwise be cost centers while long-term shared-savings metrics mature.
Care Management Software: Frequently Asked Questions
What care management directors, quality leads and finance teams ask us first.
Care management software supports the clinical and operational work delivered between encounters to patients with chronic conditions, high utilization or complex health and social needs. Unlike an EHR, which is structured around discrete visits, care management software tracks longitudinal goals, outreach, time spent on non-face-to-face services, and the documentation required to bill Medicare and commercial care management codes.
Care management focuses on longitudinal clinical oversight of an enrolled population — establishing goals, monitoring status, coordinating interventions and documenting time for billing or quality programs. Care coordination is a component of care management that specifically manages handoffs, referrals, transitions of care and information exchange across organizational boundaries. Elixir supports both within the same patient record.
Elixir logs time contemporaneously against the patient record as clinical staff perform qualifying activities — phone calls, chart reviews, care plan updates, coordination with specialists or community services. Time entries record the staff member, duration, activity type and associated care plan goal. As monthly thresholds are reached (e.g., 20 minutes for 99490), the system flags the patient as billing-eligible.
Yes, when built with structural billing rules. Federal audits (such as OIG report A-07-21-06088) frequently cite duplicate monthly claims and unallowed overlapping services (e.g., billing CCM during a TCM 30-day window). Elixir treats a patient’s care management month as a single object, preventing conflicting claims from being generated across programs or practitioners.
Elixir supports both General Behavioral Health Integration (BHI, CPT 99484) and the Psychiatric Collaborative Care Model (CoCM, CPT 99492–99494). For CoCM, the platform includes the required electronic registry: tracking validated rating scale scores (PHQ-9, GAD-7) over time, logging time against monthly thresholds (70 min initial, 60 min subsequent), and supporting weekly caseload reviews with the consulting psychiatrist.
Elixir integrates via FHIR APIs, HL7 v2 and direct database connections to exchange demographic data, clinical encounters, problem lists, medications and ADT feeds. When implemented on Salesforce Health Cloud, Elixir can either serve as the care management layer alongside an existing EHR or operate as a fully unified EHR and care management environment.
Start with one month
How many care management minutes did your team deliver last month?
If answering that takes a spreadsheet and a week, you already know where the revenue is going. Bring us one program and one month, and we will show you the work that happened and was never captured.