Patients with two or more chronic conditions receive proactive support from our clinical Care Team, which includes nutrition and lifestyle coaching, education, care coordination, and more.
Key Benefits
Monthly reimbursement for support of eligible patients
Care Team handles patient outreach, care plans, tracking, and reporting
Better clinical outcomes and reduced hospitalizations
Who It’s For
Patients diagnosed with two or more chronic conditions expected to last 12+ months
Eligible diagnoses: diabetes, hypertension, or other cardio-metabolic conditions
FDA-cleared devices with full onboarding and training
Consent collection and eligibility screening
Ongoing support, monthly check-in & care plan updates
Full documentation + time logs for audit-readiness
Patient summary reports for your review
Remote Patient Monitoring (RPM)
Patients with one or more chronic conditions receive iHealth’s FDA-cleared devices and vitals monitoring, coaching / guidance, and full oversight from our clinical Care Team.
Key Benefits
Monthly reimbursement for vitals measurement & support of eligible patients
Vitals readings are collected real-time via Bluetooth; no Wi-Fi required
Abnormal trends are identified and escalated to minimize complications
Who It’s For
Patients diagnosed with one or more chronic conditions (e.g., hypertension, diabetes)
Must use a connected monitoring device (provided to patients at no charge) to measure vitals
FDA-cleared devices with full onboarding and training
Daily vitals transmission and trend monitoring
Patient engagement, alert resolution, and escalation to provider as needed
Documentation and time logs to ensure CMS compliance
Monthly summary reports for your clinic
Value-Based Care (VBC)
We support value-based care and risk-sharing contracts with large medical organizations and payers; we engage patients, track quality-related activities, and close care gaps.
Key Benefits
Improved care quality and reduced healthcare costs
Clinics earn incentives for closing care gaps for uncontrolled patients
Detailed care gap and patient tracking reports help improve care quality
Who It’s For
ACOs, IPAs, or practices in value-based contracts
Attributed Medicare, Medicaid, or commercial patients
Organizations seeking to improve care quality or cost benchmarks
CPT Codes & Reimbursement
Not billed directly; revenue is generated through shared savings, incentives, quality bonuses, and/or risk-adjusted payments
What Unified Care Delivers
FDA-cleared devices with full onboarding and training
ACOs, IPAs, or practices in value-based contracts
Attributed Medicare, Medicaid, or commercial patients
Seeking to improve performance on care quality or cost benchmarks
Advanced Primary Care Management (APCM)
APCM expands access to coordinated, whole-person care and increases recurring revenue. We help you ensure compliance with all APCM service elements. Can be billed with RPM service codes.
Key Benefits
Receive up to $110 per enrolled patient per month (higher than CCM)
Expanded eligibility includes patients with zero, one, or multiple chronic conditions
No minimum interaction time required to bill each month (unlike CCM)
Who It’s For
Medicare Part B patients, including:
Medicare Part B patients, including:
QMB (Qualified Medicare Beneficiary) patients are eligible for enhanced reimbursement
Practice Requirements
Clinics must be able to offer or coordinate the following CMS-required service elements:
Initiating visit for new patients or those who have not been seen for 3+ years
24/7 access to a team member to address urgent issues
Care transitions and EHR-based care coordination
Performance tracking through MIPS, ACO, or other programs
CPT Codes & Reimbursement
G0556 / G0557 / G0558; reimbursement amounts are based on patient diagnoses and QMB status. Can be billed in the same month as RPM codes for eligible patients.
FDA-cleared devices with full onboarding and training
Patient outreach and digital consent collection to streamline enrollment
Setup and maintenance of electronic care plans for audit-readiness
Preparation for quality reporting under ACO, REACH, or MIPS programs
Seamless integration with RPM services to increase total reimbursement
Continuous Glucose Monitoring (CGM) Support Service
Enhance diabetes care by adding CGM support. We help patients interpret CGM data and provide guidance, while also supporting your practice with care coordination & documentation.
Key Benefits
Combining lifestyle coaching with CGM data drives better A1C outcomes
Providers can access CGM data and reports through the Unified Care portal
Care Team handles patient education, support, and follow-up
Who It’s For
Patients diagnosed with diabetes
Taking insulin or with history of hypoglycemia (<54 mg/dL)
Must meet CMS criteria for CGM coverage and have a valid prescription
Clinic visit required within 6 months prior to CGM initiation
Practice Requirements
Varies by payer and device vendor. Some Medicare patients may receive sensors at no cost. For commercial insurance, max cost is $37 per sensor and 1st sensor may be free.
What Unified Care Delivers
Program education and CGM eligibility screening
Prescription coordination and app onboarding
Ongoing lifestyle coaching by our care team and dietitians
In-app messaging support and interpretation of CGM data
End-of-wear summaries prepared for providers and patients
