MatterCCM
Fully Managed
Our clinical team runs the entire program end to end.
Healthcare happens between visits.We make sure care does too.
MatterCCM operates fully managed care programs that keep patients connected, care teams informed, and healthcare organizations in control.
Works With Your Current EHR 100% HIPAA Compliant
EHR Integration
Seamless integration. Zero duplicate data entry.
Your time belongs to your patients, not your screen. Our platform works quietly in the background, sending patient data, device readings, and care notes directly into your clinical records.
Two-Way Syncing
Demographics, meds, and care plans stay perfectly updated in your system via bi-directional HL7 FHIR.
Unified Patient Charts
Care-manager notes push directly into the EHR encounter record, giving you a complete narrative in one place.
Real-Time Peace of Mind
Urgent alerts and escalations sync instantly to the patient's chart for rapid intervention.
Simplified Scheduling
Direct appointment integration makes coordinating TCM follow-ups seamless and easy.
Automated Revenue
We export directly to major RCM platforms, taking the manual labor out of your billing process.
Developer-Friendly
Tech-forward teams love our REST API and sandbox access for custom integrations.
Onboarding
Live in 30 days, in four steps.
- Week 1–2
Discovery & Program Design
We agree the scope with your clinical and administrative leads — which programs, which populations, which devices, which protocols. EHR integration starts in parallel.
- Week 2–3
Setup & EHR Connection
Provider profiles, thresholds, care-plan templates and escalation rules are configured. The integration goes live and the billing workflow is mapped to it.
- Week 3–4
Training & Pilot Enrollment
Two to four hours of training for whoever runs the program — your staff or our care team. A pilot of 20 to 50 patients proves the workflow before it carries the full population.
- Month 2+
Full Enrollment & Optimization
Enrollment opens to everyone eligible. Monthly reviews track compliance, reimbursement and outcomes; quarterly reviews decide what to change.
Managed Clinical Services
We are not just software, we're your clinical team.
Choose managed services and our dedicated clinical team runs the day-to-day work: enrollment, device setup, monthly monitoring calls, care-plan updates and billing documentation — all under your supervising provider's name and NPI.
Clinical authority stays with you. The operational workload comes to us.
Co-Managed
Your staff keep the clinical touchpoints; we take devices, billing and reporting.
Our care team
Registered Nurses
Clinical oversight, care-plan management and escalation triage. RNs hold the clinical judgment in the program and decide when something needs your provider's attention.
Licensed Practical Nurses
Routine monitoring calls and check-ins. LPNs make the monthly contact the program is built on, and record what they hear against the care plan.
Medical Assistants
Documentation, scheduling and administrative work. The record-keeping that makes a month of care billable is done here rather than by your staff.
Enrollment Specialists
Identification, consent and activation. They work the eligible population, explain the program to patients and secure the consent the program requires.
Billing & Reimbursement
Covered CPT codes.
Each program carries its own documentation, time and consent requirements. We track all three as the work happens, so what reaches your billing team each month is ready to submit.
| Program | Key CPT codes | Medicare FFS range (approx.) |
|---|---|---|
| Chronic Care Management (CCM) | 99490, 99491, 99439 | $60–$130 / patient / mo |
| Remote Patient Monitoring (RPM) | 99453, 99454, 99457, 99458, 99445, 99470 | $100–$200 / patient / mo |
| Remote Therapeutic Monitoring (RTM) | 98975–98977, 98980, 98981 | $55–$130 / patient / mo |
| Transitional Care Management (TCM) | 99495, 99496 | $165–$230 / discharge |
| Principal Care Management (PCM) | 99424, 99425, 99426, 99427 | $60–$115 / patient / mo |
| Behavioral Health Integration (BHI) | 99484, 99492, 99493, 99494 | $50–$295 / patient / mo |
| Medication Therapy Mgmt (MTM) | 99605, 99606, 99607 | $25–$85 / patient / mo |
| Principal Illness Navigation (PIN) | G0023, G0024 | $60–$150 / patient / mo |
* Rates reflect CY2025–2026 Medicare Fee Schedule estimates. Actual reimbursement varies by geography, payer and documentation completeness.
What a Stronger Program Can Create
More continuity for patients. More control for healthcare organizations.
A well-operated care management program can support:
For patients
- More consistent patient engagement
- Greater support between encounters
- Clearer medication and care-plan follow-through
- Earlier recognition of emerging needs
For care teams
- Better-organized care coordination
- Stronger transition workflows
- Less administrative burden on existing staff
- More consistent documentation
For your organization
- Better billing readiness
- Clearer leadership visibility
- A scalable foundation for value-based care
- A more sustainable patient-care model
Program Performance
- Patient retention rate
- 95%
- Upfront cost to the practice
- $0
- Audit-ready documentation
- 100%
Actual results vary by organization, population, implementation, provider involvement, payer mix, and program design.
What the Research Shows
The need is large, and mostly unmet.
51%
of US adults reported two or more chronic conditions in 2023, rising to 79% of adults aged 65 and over.1
View source (opens in a new tab)90%
of the nation’s $5.3 trillion in annual health care spending is for people with chronic and mental health conditions.2
View source (opens in a new tab)3.4%
of Medicare beneficiaries aged 65 and over with two or more chronic conditions received CCM in 2019, up from 1.1% in 2015.3
View source (opens in a new tab)
Sources
- Watson KB, Wiltz JL, Nhim K, et al. Trends in Multiple Chronic Conditions Among US Adults, By Life Stage, Behavioral Risk Factor Surveillance System, 2013–2023. Preventing Chronic Disease 2025;22:E15. doi.org/10.5888/pcd22.240539↩
- Centers for Disease Control and Prevention. Chronic Disease Facts and Stats. Reviewed May 2026. cdc.gov↩
- Jang J, McCarthy EP, Olivieri-Mui B, et al. Use of chronic care management service among Medicare beneficiaries in 2015–2019. Journal of the American Geriatrics Society 2024;72(9):2730–2737. doi.org/10.1111/jgs.19066↩
Published industry research, not MatterCCM program results. Outcomes for any organization depend on its population, implementation and program design.
Your eligible population already exists.
The next step is determining how to serve it responsibly, consistently, and at the right scale.
MatterCCM will assess your population, current capabilities, care environment, and program goals—and recommend an operating model built around your organization.