Chronic Care Management (CCM)
20-minute monthly CCM programs billing CPT 99490 and 99439.
Care Management Software
Care Management Software Built for Real CCM Programs
We build care management platforms that operationalize chronic care management end to end — structured care plans, care-team task routing, and defensible CPT 99490/99439 time capture that survives an audit.
HIPAA-ReadyFHIR R4SOC 2 Type IIAudit Logged
Trusted by global innovators
What care management software actually involves
Care management software coordinates longitudinal care for high-risk and chronic patients across a care team — nurses, care coordinators, pharmacists, and physicians — around a shared, structured care plan. The hard part is not the UI; it is modeling FHIR CarePlan, Goal, and CareTeam resources so a plan is truly shared across systems, and capturing clinical time precisely enough to bill Chronic Care Management (CCM) codes without triggering a clawback.
Generic CRM and spreadsheet tools fail here because they cannot represent problem-oriented care plans, enforce the 20-minute monthly CCM threshold, or write structured updates back to the EHR. We build the care-management layer as a first-class clinical system: timed activities, consent capture, and interoperable care plans that flow between the platform, the EHR, and the patient.
What it is
One shared care plan across the whole care team
Care management software gives a distributed care team a single, structured plan for each high-risk patient — the goals, interventions, medications, and tasks that keep chronic conditions controlled between visits.
Done well, it captures the clinical time CCM programs bill for, keeps the EHR in sync, and surfaces the patients who need attention. Done poorly, it becomes a parallel spreadsheet no one trusts.
Architecture
A care-management data layer engineered around FHIR CarePlan and defensible time tracking — designed to interoperate with your EHR, not replace it.
What We Build Into Care Management Platforms
Each capability pairs a care-team workflow with the standard or billing rule that makes it defensible.
Structured Care Plans (FHIR CarePlan)
Problem-oriented care plans modeled on FHIR R4 CarePlan, Goal, and CareTeam resources, so each plan is shareable across the EHR and patient app instead of trapped in free-text notes.
CCM Time Tracking (CPT 99490 / 99439)
Automatic, per-activity time capture that rolls up to the 20-minute monthly CCM threshold for CPT 99490 and each additional 20 minutes for 99439, with an immutable audit trail for payer review.
Care-Team Coordination & Task Routing
Role-based task assignment, escalation, and handoffs across nurses, care coordinators, and physicians, with FHIR Task and Communication resources tracking every touchpoint.
Risk Stratification & Panel Views
Rules-based and model-assisted stratification using ICD-10 problem lists and utilization signals to surface the patients whose plans need attention this week.
Consent & Eligibility Management
Captures and versions the beneficiary consent CCM requires, tracks enrollment status, and flags patients who lapse eligibility before a claim is generated.
EHR Write-Back
Care-plan updates and CCM summaries flow back to Epic, Cerner/Oracle Health, or athenahealth via FHIR R4 and HL7 v2, so the chart stays the source of truth.
Where it fits
Care management programs we support
Principal Care Management (PCM)
Single high-risk condition management with dedicated care plans.
Complex care coordination
Multi-morbidity patients with layered goals and multiple specialists.
Payer care management
Health-plan care teams managing risk-bearing member panels.
Post-discharge follow-up
Transitional care and medication reconciliation after hospitalization.
Behavioral health integration
Collaborative care models that blend physical and behavioral goals.
Care management that pays for itself
CCM revenue depends on defensible time capture and enrolled panel size. We build both as first-class concerns instead of afterthoughts.
20 min
Monthly CCM threshold tracked automatically (CPT 99490)
FHIR R4
Care plans modeled on CarePlan, Goal, and CareTeam
3–5 mo
Typical build to first billable program
Compliance-First Healthcare App Development Services Backed by Global Standards
15-Minute Scoping Call01
HIPAA
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, strict access controls, and traceable audit logs.
02
GDPR
General Data Protection Regulation
Implement lawful consent flows, data minimization, retention controls, and secure processing for sensitive health data.
03
FHIR
Fast Healthcare Interoperability Resources
Enable standardized health data exchange across apps, care teams, and systems through robust FHIR-ready APIs.
04
HL7
Health Level Seven International
Support enterprise-grade interoperability with HL7-based integrations for records, events, and clinical messaging workflows.
05
HITRUST
Health Information Trust Alliance
Align security programs to healthcare-specific control and risk management practices trusted by providers and ecosystem partners.
06
HITECH
Health Information Technology for Economic and Clinical Health Act
Design with breach notification readiness, digital record safeguards, and operational controls that support regulated care programs.
07
SaMD
FDA Software as a Medical Device
Plan software quality, traceability, and documentation pathways for products that may require SaMD review and submission.
08
MDR (EU)
Medical Device Regulation (European Union)
Prepare EU market-ready processes for risk classification, evidence tracking, and lifecycle governance under MDR expectations.
09
SAMHSA
Substance Abuse and Mental Health Services Administration
Apply confidentiality controls and consent-aware sharing models for behavioral and mental health data experiences.
Standards and compliance
Standards behind our care management builds
FHIRHL7ICD-10CPTHIPAA
Our Process
How We Deliver a Care Management Build
A phased approach that treats care-plan modeling, billing rules, and EHR interoperability as parallel tracks from day one.
1.
Discovery & Care-Plan Modeling
We map your care programs, CCM billing rules, and target EHRs, then model the FHIR CarePlan, Goal, and CareTeam structures your workflows depend on.
Care-plan first
2.
Core Build & Time Tracking
We build the care-plan engine, task routing, and the per-activity time-capture layer that underpins CPT 99490 and 99439 claims.
Audit-ready billing
3.
EHR Integration
We wire FHIR R4 and HL7 v2 interfaces for problem lists, medications, and care-plan write-back, validated against synthetic and sandbox data.
Interoperable
4.
Rollout & Optimization
Phased go-live with care-team training, billing reconciliation dashboards, and ongoing tuning as enrolled panel size grows.
Measured scale
Featured case study
Read Case StudyLera Health: compliant women's health platform
Related proof of compliant delivery: for Lera Health we built the privacy-first data layer, longitudinal care workflow, and patient experience end to end. It is not a CCM product, but it demonstrates how we model longitudinal, consent-driven care on a HIPAA-ready foundation.
Why Partner With Us
15-Minute Scoping CallWhy teams choose Agnotic for care management
We bring the clinical-domain depth and interoperability experience to ship a care-management platform that bills correctly and survives audit.
Billing-Defensible by Design
CCM time tracking and consent capture are engineered around CMS rules from sprint one, with immutable audit logs — not reconstructed after a denial.
Care-Team Workflow Fluency
We design for how coordinators, nurses, and physicians actually hand off work, so the tool reduces coordination load instead of adding clicks.
Interoperable From Day One
FHIR R4 and HL7 v2 write-back to Epic, Cerner/Oracle Health, and athenahealth is scoped upfront, so care plans reach the chart.
Longitudinal Care Depth
We have built consent-driven, longitudinal care experiences across chronic and women's health, so your team is not educating ours.
Our relevant experience
Care coordination, engineered — not templated.
Frequently Asked Questions
Most care-management builds land between a focused CCM module and a full multi-program platform. A first billable program with FHIR care plans, time tracking, and one EHR integration typically runs a three-to-five-month engagement; broader payer-grade platforms scale from there. We scope against your programs and EHR mix before quoting.
Ready to build a care management platform that bills correctly?
Share your care programs and EHR landscape. We'll return a phased plan with care-plan modeling, CCM time tracking, and integration sequencing.
contact@agnotic.com
Partnerships
contact@agnotic.com