What comes in
Check-in received
- Patient reports a medication question
- Response captured for the care team
Chronic Care Management
Keep the monthly care program moving.
Caesar runs the outreach and prepares the monthly review for your chronic care program. Your staff make the clinical decisions and approve readiness for billing.
- Runs the recurring outreach on your cadence
- Keeps billing readiness under human control
See the work
A patient update is the start of the review.
Illustrative monthly workflows. Clinical decisions and billing approval belong to your staff.
What comes next
Clinical review task
- Patient's words attached
- Assigned under the practice protocol
A clinician reviews the concern and decides the next action.
What Chronic Care Management does
- 1Reach patient
- 2Capture update
- 3Route concern
- 4Clinician reviews
What comes in
Monthly record review
- Required evidence incomplete
- Patient remains on hold
What comes next
Staff review queue
- Hold reason recorded
- Missing item assigned for follow-up
Only a person can set Ready for Billing after the requirements clear.
What Chronic Care Management does
- 1Check record
- 2Identify hold
- 3Resolve evidence
- 4Human approval
What it handles
The monthly cycle has a place to go.
Caesar handles program logistics around your care team. Patient responses and review drafts stay connected to the record in your existing EMR.
Run consent outreach
Use your approved enrollment wording and consent pathway. Record the patient's response, including a decline or opt-out.
Make the monthly check-in
Collect the patient's update by SMS or phone using care-plan questions, then prepare the information for review.
Route concerns to staff
Apply your escalation protocol and pass the evidence to the care team. A clinician determines the clinical response.
Prepare billing review
Check the program record for required evidence. Keep a hold reason visible until the missing items are resolved.
Fits your practice
A recurring program with human review built in.
Your care plan and approved protocols define what Caesar asks and where each response goes.
- 1
Set the program
Define the consent pathway and monthly outreach schedule.
- 2
Collect the update
Run the check-in and capture the patient's response.
- 3
Review the drafts
Your staff review messages and notes before they are released.
- 4
Check billing readiness
Record the required evidence and wait for a person to approve.
Your staff provide the care and approve the claim queue.
Caesar does not give medical advice or perform clinical triage. AI activity does not count as clinical staff time. Nothing auto-bills: a person sets Ready for Billing, and your billing team submits the claim.
- Clinical review stays with qualified staff
- Every billing hold has a recorded reason
Keep your existing system.
We confirm the available connections and functions in your electronic medical record system, or EMR, before setup.
Check your EMR integration
Available functions vary by system and agent.
Before you start
Your questions, answered.
What to expect from Chronic Care Management, and what your team controls.
Is Caesar Health chronic care management software?
Yes. Chronic care management is one program within Caesar's AI workforce, alongside phone, documentation and scheduling agents. It runs recurring logistics inside your existing EMR. Your staff provide the care and review the work, rather than outsourcing the patient relationship to a call center.
Does the AI's time count toward the 20 minutes for 99490?
No. CPT 99490 requires at least 20 minutes of clinical staff time per calendar month under a physician or qualified practitioner's direction. AI conversations and administrative activity do not count as clinical minutes. Staff time is recorded as it is spent.
CMS chronic care management requirements · CCM and related code guide
Does Caesar bill on our behalf?
No. Consent, qualifying conditions, the current care plan, any required initiating visit and the applicable time threshold are checked for each patient and month. CCM includes two or more qualifying chronic conditions. A person sets Ready for Billing after the required evidence clears. Missing items retain a hold reason, and your billing team submits the claim.
Which conditions and programs does it cover?
The care plan defines the conditions, check-in questions and escalation rules. CCM and complex CCM cover multiple chronic conditions. Principal care management (PCM) focuses on a single high-risk condition. Advanced primary care management (APCM), remote therapeutic monitoring (RTM) and remote physiologic monitoring (RPM) use the shared program workflow with separate rules and available reading sources.
How is APCM different from time-based CCM?
Medicare introduced APCM in 2025 without a monthly time threshold. Eligible practices must meet the program and documentation requirements, including consent and continuity of care. Caesar organizes that evidence for human review rather than treating minutes as the basis for APCM billing.
CMS APCM requirements · CMS 2025 final rule · Compare CCM, PCM, APCM, RPM and RTM codes
Does it work with remote patient monitoring devices?
Device readings can enter through device-platform exports today. Direct telemetry adapters for blood pressure, weight, glucose and PAP adherence are in build. Device assignment, shipping and returns are on the roadmap. Confirm your vendor's export and monitoring workflow before planning an RPM or RTM launch.
What happens when a patient's condition worsens?
The agent applies the escalation tiers approved by your practice and routes the reported change to the care team with the evidence attached. It does not assess severity, perform clinical triage or give medical advice. A clinician decides the response.
Will patients know they are talking to an AI?
Yes. Your practice chooses the greeting, and the agent identifies itself as the practice's virtual assistant. It does not claim to be a person.
Do we have to change EMRs?
No. The agents read your existing chart and write monthly notes and care-plan updates back. athenahealth uses the deepest API adapter. ModMed, EZDERM and Healthie are live, while eClinicalWorks and eMedicalPractice use the browser agent where an API is unavailable.
Is the Chronic Care Management workflow HIPAA compliant?
Yes. The Chronic Care Management workflow runs on HIPAA-compliant infrastructure. Clinical information uses end-to-end encrypted infrastructure. Caesar Health executes a Business Associate Agreement (BAA) at contract signing. SOC 2 Type II is in progress.
How does enrollment and monthly outreach work?
The agent uses your approved consent and cost-sharing wording, records consent or a decline with a timestamp, and honors opt-outs. Monthly SMS or phone check-ins collect patient-reported symptoms, medication updates and readings against the care plan. Outreach follows do-not-contact rules, attempt limits, quiet hours and local-time windows.
What do staff review, and what is recorded for audit?
Staff approve, edit or escalate monthly summaries, patient messages and chart-note drafts before release. Each action records its trigger, inputs, applied rule and approver. The task hub and exception queue retain the decision history for each patient and month.
What is live today, and what is still being built?
Outreach, timestamped consent, the monthly review cycle and human-controlled billing gates are live. Direct device telemetry adapters are in build. Device logistics and per-program leadership reporting are on the roadmap. Automated insurance eligibility and benefits checks before enrollment are not built.
How is this different from an outsourced CCM service or a dashboard?
An outsourced service supplies people to run the program. A dashboard gives your staff tracking tools. Caesar runs recurring outreach and preparation while your own staff review the record and provide clinical care. If you have no clinical staff available, software does not supply that clinical capacity.
Chronic Care Management
Map your monthly program with us.
Start with the patients you serve and the review work your care team needs to keep.
Book a demo