Subtotal:
$0.00
Trusted By 500+ U.S. Healthcare Providers
Build CCM Software
that Works for You—
Not Against You
Design chronic care management software that adapts to your workflows—streamlining operations with automation, real-time monitoring, and personalized care workflows.
Seamless Patient Onboarding
Personalized Care Planning
Smart Patient Management
Intuitive Dashboards
Real-Time Patient Monitoring
Proactive Patient Engagement
Automated Billing & Reimbursement
Automate Your Workflows from Onboarding to Billing with Custom CCM Software
Build chronic care management software that streamlines every step of your CCM program—automating patient onboarding, care planning, monitoring, engagement, and billing.
Seamless Patient Onboarding
Quickly onboard patients from consultation to your CCM program with one guided flow— from eligibility and enrollment to care plan setup.
- Smooth EHR Integration
- One-Click Patient Chart Creation
- Guided Patient Assessment
- Automated CCM Eligibility Checks
- Digital Consent Management
Personalized Care Planning
Create individualized care plans using customizable templates and dashboards that help your team deliver accurate, holistic, and consistent chronic care.
- Condition-Specific Care Plan Library
- Instant Care Plan Assignment
- Patient-Centered Care Plan Builder
- Care Goals & Progress Tracking
Smart Patient Management
Manage everything from patient data to ongoing care delivery with intelligent tools that simplify workflows, improve coordination, and keep your team aligned.
- Smart Patient Filters for Quick Sorting
- Automated Alerts & Reminders
- Personalized Patient Dashboard
- Quick Patient Charting
Intuitive Dashboards
Create custom dashboards that centralize patient data, highlight key insights, and make CCM workflows easier to manage at a glance.
- Patient Health Insights at a Glance
- Automated Progress Tracking
- Care Team Task Overview
- Data-Driven Care-Plan Suggestions
- Customizable Dashboard View
Real-Time Patient Monitoring
Track patient vitals, symptom changes, and care progress in real time with secure monitoring tools that keep your team informed and ready to act.
- Interactive Patient Assessments
- Streamlined Care Plan Updates
- Patient Education Resources
- Auto-Synced Vitals & Alerts
- Daily Care Goal Tracking
Proactive Patient Engagement
Keep patients actively involved in their care with streamlined scheduling, secure communication, and automated reminders that support continuous engagement.
- Integrated Calendar Management
- Quick Appointment Scheduling
- Built-In Telehealth Access
- Secure Two-Way Messaging
- Automated Reminders & Alerts
Automated Billing &
Reimbursement
Simplify your CCM billing with automated time tracking, accurate coding, and easy claim submission—ensuring faster reimbursements and complete audit-ready documentation.
- Automated Time Logging & Coding
- Audit-Ready Accounting Logs
- Patient-Specific Time Tracking
- Accurate Billing Report Generation
- End-to-End Reimbursement Tracking
See How Clinicians Like You Have Transformed Their
CCM Programs with A&I
From proactive care delivery to better patient outcomes—these success stories show the real impact of A&I’s custom CCM solutions.
CCM Finally Works the Way We Needed
"Our CCM program used to feel chaotic—too much manual tracking, too many missed follow-ups. A&I built us a system that fits how our clinicians actually work. Time logging is automatic, monitoring is real-time, and our care plans are finally easy to update. For the first time, CCM feels manageable, not overwhelming. ” Show More
Harmony Care Group, Texas
From Reactive to Proactive in Just Weeks
“Before A&I, our team only reacted when patients called with issues. Now the dashboard alerts early, we schedule follow-ups faster, and nothing falls through the cracks. It genuinely changed how our staff communicates and cares for chronic patients. ” Show More
HealthPlus Clinic, Ohio
Care Plans Are Finally Easy to Manage
“A&I’s customized CCM tools made care coordination smoother than ever. Updating care plans, tracking goals, and reviewing patient progress is now simple and organized. Our nurses feel more confident, and our patients feel more supported between visits. ” Show More
Primary Care, North Carolina
CCM Revenue Up, Workload Down
“We always knew CCM had potential, but we didn’t have the right system to support it. A&I gave us a custom platform that automated scheduling, time tracking, and billing. Our reimbursements increased, our workflows improved, and our staff finally stopped dreading CCM documentation.” Show More
Riverbend Health Partners, Colorado
Real Results from Clinics Using
Custom CCM Solutions
See how providers improved care coordination, boosted engagement, and captured more CCM revenue with solutions tailored to their workflows.
CCM Program Director
Dr. Emily Warren
Oakview Primary Care Associates
Before A&I, our CCM workflow was scattered across spreadsheets and EHR notes. We constantly missed monthly touches and lost track of care minutes. With their custom platform, everything happens in one place — automated time logs, care plan reminders, and real-time alerts. Our nurses finally feel in control instead of overwhelmed. "
Key Results
54% increase in completed monthly CCM touches
41% reduction in missed care minutes
hidden
36% faster care plan updates
minutes
29% fewer patient escalations
Implementation Time:
4 Months
Systems Integrated:
7
Billing Manager
Linda Matthews
NorthPoint Family Health Center
Our billing errors used to kill our CCM revenue. Documentation wasn’t aligned with time logs, and audits always revealed gaps. A&I automated everything — coding, time tracking, audit logs, and claims prep. For the first time, our CCM reimbursements are predictable and accurate. "
Key Results
48% reduction in billing errors
31% increase in CCM reimbursement revenue
hidden
63% faster claim submission cycle
100% audit-ready documentation compliance
Implementation Time:
3 Months
Systems Integrated:
9
RN, Chronic Care Nurse Lead
Karen Li
Westlake Health Network
We used to rely on patients to tell us when something was wrong. Now the monitoring dashboard flags vitals, symptoms, and risk scores automatically. We’ve caught hypertension spikes, medication lapses, and behavioral changes early — before they turned into ER visits. "
Key Results
37% reduction in high-risk escalations
26% improvement in medication adherence
hidden
49% faster response to symptom changes
22% fewer preventable ED visits
Implementation Time:
5 Months
Systems Integrated:
8
MD
Michael Harries
HealthPlus Clinic, Ohio
Our CCM patients used to be hard to reach — missed calls, voicemail loops, no-shows. A&I gave us automated reminders, easy scheduling, and telehealth built right in. Patients are more responsive, and our team isn’t wasting time dialling numbers all day. "
Key Results
43% drop in no-shows for CCM calls
2.3 minutes saved per outreach attempt
hidden
51% increase in patient response rate
33% improvement in care plan adherence
Implementation Time:
4 Months
Systems Integrated:
6
Build a CCM Software that Aligns with Your Workflows
Connect with A&I to design a compliant, custom CCM platform that fits your workflows and makes patient management simpler, faster, and more organized.
Frequently Asked Questions
Q. What is CCM software, and how can a custom-built solution support Medicare-eligible
chronic care patients?
chronic care patients?
Custom CCM software centralizes care plans, time tracking, patient communication, vitals, and follow-ups for Medicare patients with two or more chronic conditions. A custom-built platform lets clinics tailor workflows, automate required documentation, ensure CMS-compliant processes, and deliver proactive, coordinated care for high-risk patients without relying on rigid, off-the-shelf systems.
Q. What Medicare billing requirements (99490, 99439, 99487, 99489) should a custom CCM platform support?
A custom CCM platform should automate time capture, support electronic care plans, record non-face-to-face activities, and map minutes to appropriate codes. It must distinguish between regular and complex CCM, manage add-on minutes, prevent double-counting, and generate audit-ready logs. Built-in compliance rules ensure every claim meets CMS documentation and supervision requirements.
Q. Can custom CCM software streamline the patient consent workflow required by Medicare?
Yes, custom software can digitize consent collection, store it in the patient record, verify eligibility, and track consent status automatically. It ensures compliance with CMS requirements by documenting patient understanding of cost-sharing, program details, and the right to discontinue. Automated workflows eliminate manual paperwork and prevent enrollment or billing errors.
Q. How does custom CCM software automate monthly time tracking and documentation for billable minutes?
Custom CCM software logs time automatically as staff complete calls, assessments, care-plan updates, coordination tasks, and messaging. Each action is time-stamped and linked to the patient’s record. The system aggregates minutes, prevents overlap with other programs, and generates monthly billing summaries, ensuring accurate, CMS-compliant documentation without manual spreadsheet tracking.
Q. How can software support the differences between Regular CCM and Complex CCM under Medicare rules?
Custom software can separate regular and complex CCM workflows by tracking required time thresholds, medical decision-making complexity, care-plan elements, and add-on minutes. It can guide staff through the correct documentation, flag when a patient qualifies for complex CCM, and ensure billing codes match clinical complexity, simplifying compliance and reimbursement accuracy.
Q. Can custom CCM platforms support combined billing for CCM and RPM in the same month?
Yes, a custom platform can track CCM and RPM activities separately, ensuring minutes aren’t double-counted and each program meets CMS criteria. Automated logic can assign tasks to the correct service, synchronize device data, and generate clean billing reports. This allows clinics to run both programs efficiently while maintaining full compliance.
Q. How does custom CCM software integrate with existing EHR/EMR systems to prevent
duplicate charting?
duplicate charting?
Custom CCM software integrates via FHIR or APIs to sync notes, care plans, vitals, assessments, and outreach activity directly into the EHR. Bi-directional syncing ensures providers' charts are updated once, and data appears everywhere it’s needed. This eliminates duplicate work, keeps records aligned, and simplifies billing, documentation, and care-coordination workflows across systems.
Q. Which care activities can be tracked automatically in CCM software for compliant monthly billing time?
Custom CCM software can automatically record time spent on medication reviews, symptom checks, care-plan updates, coordination with specialists, patient or caregiver communication, vitals review, and education. These non-face-to-face activities count toward CCM billing. The system excludes ineligible tasks and creates CMS-ready logs to ensure accurate, compliant billing.
Q. How can CCM software support better outcomes and reduce hospital readmissions through proactive care workflows?
Custom CCM software enables continuous patient monitoring, timely follow-ups, automated reminders, medication adherence tracking, and early detection of worsening symptoms. By surfacing risk alerts and coordinating care quickly, clinics can intervene before issues escalate. This proactive oversight reduces avoidable ED visits, stabilizes chronic conditions, and improves long-term patient outcomes.
Q. Which providers can bill for CCM, and how can software ensure compliance with CMS supervision and documentation rules?
Physicians, NPs, PAs, CNSs, and CNMs can bill CCM while clinical staff deliver services under proper supervision. Custom software ensures compliance by maintaining electronic care plans, logging staff activities, validating supervision requirements, and preventing billing conflicts. Automated audit trails help clinics meet CMS documentation standards with far less administrative burden.