À la carte
Launch one priority program—such as RPM, CCM, TCM, or BHI—with the workflow and staffing needed to make it operational.
Request an assessment CARE PROGRAMS
Match the program to the patient—not the other way around.
PrimeVital helps organizations identify the programs that fit their population, operating capacity, payer mix, and clinical priorities.
Request a population reviewEXPLORE THE NINE-PROGRAM PORTFOLIO
Choose a program to see who it serves and what it takes to run.
The descriptions below reuse the strongest material from your existing site and add a practical view of patient fit, care experience, workflow, and coverage.
RPM
Remote Patient Monitoring
Connected physiologic data for acute or chronic conditions where readings between visits can guide care.
Vitals and device dataView program detailsRTM
Remote Therapeutic Monitoring
Non-physiologic treatment information focused on therapy response, adherence, and function.
Therapy progressView program detailsCCM
Chronic Care Management
Ongoing monthly coordination for a patient managing multiple chronic conditions.
Whole-person coordinationView program detailsPCM
Principal Care Management
Disease-specific monthly support centered on one complex, high-risk chronic condition.
Condition-specific careView program detailsTCM
Transitional Care Management
Structured clinical and operational follow-through during the 30 days after an eligible discharge.
Post-discharge continuityView program detailsBHI
Behavioral Health Integration
Behavioral and psychiatric care-management support integrated with medical care.
Behavioral supportView program detailsAPCM
Advanced Primary Care Management
A risk-tiered monthly primary-care bundle designed around comprehensive, continuous care.
Advanced primary careView program detailsMTM
Medication Therapy Management
Medication optimization for targeted beneficiaries through a Medicare Part D plan program.
Medication outcomesView program detailsPIN
Principal Illness Navigation
Navigation support around one serious, high-risk condition and the barriers surrounding it.
Serious-illness navigationView program detailsDESIGNED AROUND YOUR READINESS
À la carte when the need is focused. Coordinated when the patient journey is not.
Focused bundle
Connect complementary programs for a defined population, such as RPM with CCM or post-discharge TCM with ongoing monitoring.
Coordinated portfolio
Support three or more programs across the organization with common enrollment, separate program-level records, and unified reporting.
One patient view. Distinct program records.
When multiple services are appropriate, time and work can be tracked separately by program. The same minute or clinical effort cannot be counted twice, and each service must independently meet current payer requirements.
PROGRAM DETAILS
Useful information for a clinical and operational decision.
Each overview is intentionally practical—not a reimbursement promise or a substitute for current payer and coding guidance.
See how to evaluate payer pathway and operating economicsRPM
Remote Patient Monitoring
Connected physiologic data for acute or chronic conditions where readings between visits can guide care.
Best suited for
Patients with conditions such as hypertension, diabetes, heart failure, COPD, or another acute or chronic condition that is medically appropriate for physiologic monitoring.
What the patient experiences
The patient uses a connected medical device—such as a blood-pressure cuff, scale, glucose meter, or pulse oximeter—and the care team reviews transmitted readings and follows up when needed.
What the operating workflow needs
- Identify eligible patients and obtain consent
- Set up the connected device and patient education
- Review readings, prioritize exceptions, and engage the patient
- Document treatment-management work and maintain billing-ready records
Coverage lens
Original Medicare covers medically necessary RPM for qualifying acute and chronic conditions. Device, data-transmission, treatment-management, practitioner, and frequency requirements must be validated for the current payer.
Compare payer-specific questionsRTM
Remote Therapeutic Monitoring
Non-physiologic treatment information focused on therapy response, adherence, and function.
Best suited for
Appropriate musculoskeletal, respiratory, physical-therapy, post-surgical, pain-management, and other qualified therapeutic pathways.
What the patient experiences
The patient reports or transmits information about therapy adherence, response, symptoms, or function while the practitioner uses that information to manage treatment.
What the operating workflow needs
- Match the treatment pathway and qualified practitioner
- Activate the approved device or software workflow
- Review adherence and response between visits
- Document qualified treatment-management interaction and distinct time
Coverage lens
RTM is different from RPM and generally cannot be billed concurrently with RPM for the same patient. Eligible device, data, practitioner, interaction, and payer rules must be checked.
Compare payer-specific questionsCCM
Chronic Care Management
Ongoing monthly coordination for a patient managing multiple chronic conditions.
Best suited for
Patients with two or more chronic conditions expected to last at least 12 months—or until death—that create significant clinical risk.
What the patient experiences
A care team maintains a comprehensive care plan, coordinates across providers and services, reviews medications, and supports the patient between office visits.
What the operating workflow needs
- Confirm condition and risk criteria
- Complete the initiating visit when required and obtain consent
- Create and maintain a comprehensive care plan
- Capture qualifying monthly care-management work without duplicate time
Coverage lens
CCM is a Medicare Part B care-management service, but patient cost sharing, responsible practitioner, service time, concurrent services, and payer-specific requirements must be reviewed.
Compare payer-specific questionsPCM
Principal Care Management
Disease-specific monthly support centered on one complex, high-risk chronic condition.
Best suited for
Patients with one serious chronic condition expected to last at least three months and placing them at significant risk of hospitalization, deterioration, or death.
What the patient experiences
The care team concentrates on the disease-specific plan, medications, treatment changes, specialist coordination, symptoms, and patient goals for the principal condition.
What the operating workflow needs
- Validate the single-condition clinical criteria
- Establish the disease-specific care plan
- Coordinate the specialist and broader care team
- Track the required monthly work and avoid duplicate service time
Coverage lens
Medicare PCM requirements include a qualifying condition, care plan, initiating relationship, responsible practitioner, and monthly service requirements. Coverage varies outside Original Medicare.
Compare payer-specific questionsTCM
Transitional Care Management
Structured clinical and operational follow-through during the 30 days after an eligible discharge.
Best suited for
Patients returning to a community setting after an eligible inpatient, observation, skilled-nursing, rehabilitation, psychiatric, or partial-hospitalization discharge.
What the patient experiences
The practice establishes timely contact, reconciles medications, coordinates needed services, assumes responsibility for the transition, and completes the required follow-up visit.
What the operating workflow needs
- Receive reliable discharge notification
- Contact the patient within the required window
- Reconcile medications and coordinate services
- Complete the required visit and document the full 30-day transition
Coverage lens
Medicare TCM has specific discharge settings, communication windows, visit timing, medical-decision-making, and billing-period rules. Every transition must be checked individually.
Compare payer-specific questionsBHI
Behavioral Health Integration
Behavioral and psychiatric care-management support integrated with medical care.
Best suited for
Patients with an identified mental, behavioral, psychiatric, or substance-use condition that requires assessment, planning, intervention, and ongoing coordination.
What the patient experiences
The patient receives behavioral-health assessment, a care plan, systematic follow-up, coordinated interventions, and connection between behavioral and medical care.
What the operating workflow needs
- Establish the condition and initiating relationship
- Develop the behavioral-health care plan
- Provide and track coordinated interventions and follow-up
- Maintain the required care-team oversight and monthly record
Coverage lens
Medicare supports general BHI and the Psychiatric Collaborative Care Model under different requirements. Practitioner, care-team, time, supervision, and concurrent-service rules vary.
Compare payer-specific questionsAPCM
Advanced Primary Care Management
A risk-tiered monthly primary-care bundle designed around comprehensive, continuous care.
Best suited for
Primary-care practices serving as the continuing focal point for a patient’s overall care and able to deliver the required access, coordination, planning, and population-management capabilities.
What the patient experiences
Patients receive continuous access, a comprehensive electronic care plan, care-transition support, coordinated medical and social care, and enhanced communication options.
What the operating workflow needs
- Confirm that the practice meets the advanced-primary-care model
- Select the appropriate patient-complexity level and obtain consent
- Deliver the applicable comprehensive service elements
- Maintain population management and performance reporting
Coverage lens
APCM is billed monthly and is not minute-based. It incorporates elements of several care-management and communication services, so overlap and exclusion rules require careful review.
Compare payer-specific questionsMTM
Medication Therapy Management
Medication optimization for targeted beneficiaries through a Medicare Part D plan program.
Best suited for
Targeted Part D beneficiaries who meet their plan’s criteria, often involving multiple chronic diseases, multiple covered medications, and plan-defined drug-cost thresholds.
What the patient experiences
A pharmacist or other qualified provider reviews the medication regimen, identifies interactions or duplications, discusses adherence and goals, and develops an action plan.
What the operating workflow needs
- Confirm eligibility through the patient’s Part D plan
- Complete the comprehensive medication review
- Create the medication list and patient action plan
- Coordinate findings and follow-up with the patient and prescribers
Coverage lens
MTM is a Part D sponsor program—not simply another Physician Fee Schedule service. Eligibility, delivery model, documentation, and payment are defined through the patient’s plan.
Compare payer-specific questionsPIN
Principal Illness Navigation
Navigation support around one serious, high-risk condition and the barriers surrounding it.
Best suited for
Patients with one serious, high-risk condition expected to last at least three months and requiring a disease-specific care plan, frequent treatment changes, or substantial caregiver support.
What the patient experiences
A trained navigator helps the patient understand the care plan, schedule and coordinate services, overcome access barriers, communicate with the care team, and build self-advocacy skills.
What the operating workflow needs
- Complete an initiating visit addressing the serious condition
- Develop or confirm the disease-specific plan
- Assign qualified navigation personnel under required supervision
- Document navigation activities, time, consent, and care-team communication
Coverage lens
Medicare PIN has specific condition, initiating-visit, personnel, consent, time, and supervision rules. Separate codes exist for navigation involving behavioral-health conditions.
Compare payer-specific questionsILLUSTRATIVE PROGRAM COMBINATIONS
One patient may need more than one kind of support.
These are examples—not an exhaustive list and not automatic billing combinations. The appropriate pathway depends on the patient, responsible practitioner, distinct work, timing, non-duplication rules, and the exact payer.
Program coverage and reimbursement vary by patient, payer, plan, locality, provider type, contract, and current policy. PrimeVital supports operational and billing readiness; final clinical, coding, and billing decisions remain with the provider organization.
DESIGN A PRACTICAL STARTING POINT
Tell us where the workflow is breaking. We’ll show you where to begin.
Choose how to connect
Continue on your phoneScan to open a pre-addressed email draft.Email contact@theprimevital.com