Chronic Care Management (CCM):

Continuous Care for Better Lives, Anywhere, Anytime

Managing chronic conditions shouldn’t be limited to a clinic. Esvyda provides a comprehensive, HIPAA-compliant CCM solution designed to support patients with two or more chronic conditions.

We empower healthcare providers to deliver proactive, coordinated care that improves patient outcomes while maximizing practice revenue.

Key Features of the Esvyda CCM Solution

• Personalized Digital Care Plans

  Build and manage comprehensive, patient-centered care plans that track goals, medications, and external factors in real-time.

• Bilingual Care Coordination

  Our platform and support center are bilingual (English/Spanish), ensuring clear communication for diverse patient populations.

• 24/7 Access and Engagement

  Automated reminders for appointments, medications and messaging. Keeping the care team and family members connected.

• Smart Billing Engine

  Automate CPT coding (99490, 99439, 99487) with time-tracking and smart reporting to ensure accurate reimbursement.

Benefits for Providers

• Accurate billing

  Capture monthly reimbursements for non-face-to-face care coordination.

• Streamlined Workflow

  Integration with major EHRs like Athena Health reduces administrative burden.

• Data-Driven Decisions

  Real-time dashboards provide a holistic view of population health.

Benefits for Patients

• Reduced Hospitalizations

  Proactive monitoring catches complications before they become emergencies.

• Enhanced Medication Adherence

  Smart alerts and engaging support help patients stay on the right track.

• Family Inclusion

  Authorized family members can stay informed and motivated in the care journey.

How It Works: The Esvyda CCM Journey

A simple, 4-step process to show providers and patients how seamless care coordination can be.

Step 1:

Patient Identification and Enrollment

We help your practice identify eligible patients with two or more chronic conditions using data-driven insights. Our team, if authorized, can handle the formal consent process, ensuring all CMS requirements are met from day one.

Features:

• EHR/EMR enrollment
• Eligibility verification
• Consent forms
• Smart screening

Step 2:

Personalized Care Plan Development

A comprehensive, digital care plan is established within the Esvyda platform. This includes health goals, medication lists, and specific interventions tailored to the patient’s unique needs and cultural background.

Features:

• Goals
• Targets
• Medication management
• Care plan setup
• Care plan programs
• Staff tasks

Step 3:

Continuous Remote Monitoring and Support

Patients receive 20+ minutes of non-face-to-face care coordination each month. This includes HIPAA-compliant messaging, phone check-ins, and the integration of real-time data from connected health devices.

Features:

• Alerts, notifications and reminders
• Secure messages
• Secure phone calls
• Video calls
• Health data synchronization
• Service time tracking

Step 4:

Automated Billing and Reporting

At the end of each month, our “Smart Billing Engine” generates audit-ready reports. We track every minute of clinical staff time and provide the necessary documentation for CPT codes, ensuring your practice is reimbursed accurately.

Features:

• Service time tracker
• Claims wizard
• Billing reports
• Billing compliance dashboard
• Graphic dashboards

See billable CCM CPT Codes

• 99490

  Reimbursement for the first 20 minutes of time that clinical staff spends with a patient.

• 99439

  Reimbursement for additional 20 minutes of time that clinical staff spends with a patient.

• 99487

  60 minutes per month of Complex CCM.

Ready to Launch Your CCM Program?

Schedule a 15-minute Revenue Assessment

Transform the way you deliver healthcare with our innovative virtual health platform. Esvyda enables you to extend your range of services, reach more patients, increase treatment engagement, and significantly increase your revenue streams.