From the moment a patient file arrives to the billing package sent — every step our team handles on your behalf, every month, for every enrolled patient.
Zero cost to patients. Secondary insurance handles any copay.
Every interaction recorded, transcribed, and audit-ready.
Steps 3–8 repeat automatically each month until unenrollment.
A Medicare Part B covered monthly coordination programme — run entirely by our team on behalf of your physicians.
Monthly check-in coordinated by a dedicated care coordinator on behalf of the physician
Phone, email, and text outreach each month — call always attempted first
Covers medication adherence, vitals, therapy, specialist visits, and emotional well-being
Coordinates with PCP, home health, pharmacy, family, RPM providers, and assisted living
Every interaction recorded, transcribed, summarised — billing package prepared monthly
Patient must have Medicare as primary insurance
Ensures zero out-of-pocket — we verify before first contact
e.g. Diabetes + Hypertension, CHF + CKD, COPD + Anxiety
We receive the referral — we do not self-enroll patients
Every patient follows this structured cycle — repeated until the patient unenrolls. Steps 03–08 run every month.
Doctor’s office sends care plan, insurance details, and patient chart to our team
Detailed care plan created. Month-1 questionnaire tailored to patient’s specific conditions
Coordinator calls patient — explains CCM, verifies consent and confirms insurance coverage
Per CCM guidelines, email + text sent same day if call goes unanswered
Contacts PCP, home health, pharmacy, family, RPM provider, and assisted living as needed
Every interaction recorded with consent, transcribed, and summarised via NeuralWave AI
Physician reviews notes, escalations flagged and handled, EHR updated if access given
Summary + time log + evidence sent to billing. CPT 99490 / 99439 submitted to Medicare
A live example — Robert Martinez, age 73, Type 2 Diabetes + Hypertension + CHF.
Tailored to care plan conditions:
Condition 1: Diabetes T2 — FBG 80–130 mg/dL, HbA1c < 7.5%
Condition 2: Hypertension — BP < 130/80 mmHg
Condition 3: CHF — stable weight, no fluid overload
Dear Mr. Martinez, we attempted to reach you by phone today. This is your first monthly CCM check-in — fully covered by Medicare, with any copay covered by your secondary insurance, at no out-of-pocket cost. Quick questions: any ankle swelling or shortness of breath? Taking Furosemide, Metformin, and Carvedilol as prescribed? Please reply or call 555-800-1234.
Hi Mr. Martinez — this is your Care Coordinator from your physician’s office. We tried calling for your monthly CCM check-in (fully covered by Medicare, no out-of-pocket cost). Quick questions: ankle swelling improving? Taking all meds? Recent weight + BP? Any shortness of breath? Please reply or call 555-800-1234.
After every patient interaction we coordinate with the full care network — PCP, home health, pharmacy, RPM provider, family, caregiver, and assisted living where applicable.
Patient summary with health updates and care actions
Time log: 20 min coordinator + 5 min physician = 25 min total
Call recording file (audio evidence)
Auto-generated transcript (text evidence)
RPM data export from VitalTrack (supporting evidence)
Billing team submits CPT 99490 / 99439 to Medicare
From patient file to billing package — every step handled, every month, for every enrolled patient.
If you want to start — or restart — CCM without the operational burden, this is the conversation.
hello@innovosoltech.cominnovosoltech.com