Is this a time-limited transition after discharge?
Start with TCM. It covers a defined 30-day transition from a qualifying setting and requires timely contact plus a clinical visit.
Program fit
Start with the patient need. Then choose the program.
These names describe different services, not a menu to bill for every patient. The right fit depends on the condition, care setting, clinical owner, service requirements, and work already being provided. MySeema helps partners turn the selected model into outreach, coordination, documentation, and follow-through.
Which need are you trying to support?
Is the need ongoing chronic-condition management?
Compare CCM for multiple chronic conditions, PCM for one high-risk chronic condition, and APCM for a broader primary-care relationship led by the focal primary-care practitioner.
Is the care team using information gathered remotely?
Compare RPM for automatically transmitted physiologic readings with RTM for nonphysiologic information about a prescribed therapy.
Is the need behavioral health, a barrier to medical care, or serious-illness navigation?
Use BHI for integrated behavioral-health care, CHI for social or practical barriers that impede diagnosis or treatment, and PIN for navigation around one serious, high-risk illness.
Is the need a Medicare Part D medication review?
Use the patient's Part D plan MTM pathway. MySeema may help the patient connect and complete follow-through, but MTM is not another standard physician-billed Part B monthly program.
Different services. Different starting points.
On smaller screens, swipe to read the full comparison.
| Program | Patient need | Time horizon | Coordination role |
|---|---|---|---|
| CCM | Two or more chronic conditions requiring a comprehensive care plan | Ongoing, generally monthly | Outreach, care-plan follow-through, coordination, documentation, and escalation |
| TCM | Return to the community after a qualifying facility stay | 30 days beginning at discharge | Discharge outreach, appointments, records, practical support, and documented handoffs |
| PCM | One complex, high-risk chronic condition | Ongoing, condition-specific | Condition-focused outreach, coordination, documentation, and escalation |
| APCM | Broad continuity around an ongoing primary-care relationship | Ongoing monthly bundle | Assigned outreach, coordination, transition follow-through, documentation, and reporting |
| RPM | Physiologic readings gathered at home to help manage a condition | Defined monitoring episode or ongoing need | Device onboarding support, participation follow-up, documentation, and protocol-based escalation |
| RTM | Adherence, symptoms, function, or response related to prescribed therapy | Defined therapy-monitoring episode or ongoing need | Onboarding, engagement, practical follow-through, documentation, and escalation |
| BHI | Behavioral-health care integrated with the patient's broader medical care | Ongoing under the selected BHI model | Patient engagement, coordination, practical follow-through, documentation, and safety escalation |
| CHI | Social or practical barriers that significantly impede diagnosis or treatment | As needed around the identified barriers | Focused resource navigation, connection, follow-through, and documentation |
| PIN | Navigation around one serious, high-risk illness and its treatment plan | Disease-specific, generally ongoing while needed | Disease-pathway coordination, barriers, appointments, records, and follow-through |
| MTM | Part D plan member eligible for a structured medication review | According to the Part D plan's MTM program | Connection to the plan program, question preparation, and medication-related follow-through |
Choose the workflow before estimating reimbursement.
A larger estimate does not make a program the right choice.
Start with the patient’s need, the responsible clinical team and the work you can document. Then use the matching service scenario to explore financial assumptions.
A closer look at CCM, PCM and APCM →- One selected program and scenario at a time in the estimator.
- Do not count the same staff time twice.
- A bundle may replace existing billable services.
- A patient may decline participation or stop services.
We can help you map the next step.
Tell us the patient need and the workflow that needs support.