Full-Service CCM for Your Practice

The Foundation

CCM is a Medicare-reimbursed program (CPT 99490) for patients with two or more chronic conditions. It enables practices to provide structured, ongoing monthly support — and get paid for it. Dula Health Solutions manages the entire program on your behalf.

• Monthly patient check-ins (20+ min non-face-to-face)
• Medication management and adherence tracking
• Medication reconciliation and adherence support
• Coordination with specialists and other providers
• Billed under CPT 99490 — ~$64/patient/month

Patient Enrollment

We identify eligible patients in your panel — Medicare beneficiaries with two or more chronic conditions — and handle the consent and enrollment process. Most primary care practices have more qualifying patients than they realize.

• Medicare patients with 2+ chronic conditions
• We conduct patient outreach and patients must consent to participate
• Conditions include diabetes, hypertension, COPD, CHF, and more
• Typical practices enroll 50–200+ patients

Operations

Our team handles all CCM documentation and monthly patient touchpoints, then submits the correct CPT codes to your billing department — so your staff isn't burdened. We integrate with your existing EHR and ensure your practice captures every dollar it's owed.

• All documentation handled by our care coordinators
• Monthly patient phone check-ins and follow-up documentation
• Seamless EHR integration (Epic, Athena, eClinicalWorks, and more)
• CPT codes submitted directly to your billing department
• Monthly reporting on enrolled patients and revenue generated