Care management services

Priority Health reimburses, fee for service, for care management services. Reimbursement is available to primary care and specialty physicians and, when indicated, to qualified health professionals (QHPs)*.

Applies to:

All plans; see coding notes

Eligible patients

To be enrolled in care management, patients:

  • Are classified as moderate or high risk based on health history
  • Have one or more chronic conditions
  • Have a completed care plan that meets documentation requirements
  • Receive care by a trained qualified health provider* (QHP) and working within a structured care team

Reimbursement rates

Find reimbursement rates for the codes listed on this page in our standard fee schedules for your contract. Go to the fee schedules.

Billable care management codes

The CPT and HCPCS manuals define billing and coding requirements for both physician and non-physician QHP* care management services.

Scroll down this page to billing help and documentation requirements for these codes:

  • G0511
  • G0512
  • G9001
  • G9002
  • G9007
  • G9008
  • G9678
  • 98966
  • 98967
  • 98968
  • 99484
  • 99487
  • 99489
  • 99490
  • 99492
  • 99493
  • 99494
  • 99495
  • 99496

Telephone visits by QHP*

See the Telephone and e-visitspage.

Special process for commercial (HMO, POS, PPO) care management G-code and QHP* telephone visit claim payment

Medicare and Medicaid care management service claims process through our regular claims system.

However, Priority Health has a unique process for paying G-code and telephone visit care management services for commercial employer group and MyPriority® individual members. 

  1. Practices bill care management G-codes and telephone visit CPT services with their practice charges.
  2. Priority Health auto-adjudicates claims, applying a $0 payment.

    On the Remittance Advice, the $0 payment yields full allowed dollars as provider liability.

    The Remittance Advice processing code is CO96, "no compensation allowed for this service - reporting only."

    The member's claim explanation displays $0 member liability. No copayment or deductible applies.

  3. Every 60 days, Priority Health batches a payment for the full allowed amount of each practice's billed G-codes and CPT codes with no member copayment or deductible.

    These payments are processed with a paper check.

    The check payment and Remittance Advice report are mailed to the provider's claims remittance advice address.

    A Remittance Advice report designates claim detail such as member demographics, billed codes and date of service.

Care management code details

Priority Health recognizes the value of care management services that are integral to the patient-centered medical home, and reimburses for them.

G0511, Rural health clinic or federally qualified health center (RHC or FQHC) only, general care management

Documentation requirements

  • At least 20 minutes of care coordination services documented in the calendar month
  • Services are provided under the direction of the RHC or FQHC physician, NP, PA or CNM
  • Services are provided by an RHC or FQHC practitioner or by clinical personnel under general supervision
  • Beneficiary consent is obtained
  • Care plan is updated with changes in care or chronic conditions
  • Evidence of coordination of care between providers and the facilities used

Tips

Eligible patients are those that have: 

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, and place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,
    or
  • Any behavioral health or psychiatric condition being treated by the RHC or FQHC practitioner, including substance use disorders, that, in the clinical judgment of the RHC or FQHC practitioner, warrants BHI services. 

Further:

  • Only one practitioner can furnish and be paid for care coordination services during a calendar month
  • PHI must be in a certified EHR
  • Patient must have 24/7 access to care.
  • Care includes management of patients' medical, functional and psychosocial needs.
  • Enhanced communication such as secure messaging, telephone or other non-face to face communication between the patient and practitioner.

G0512, Rural health clinic or federally qualified health center (RHC or FQHC) only, psychiatric care management

Documentation requirements

  • Initiating visit: An E/M, AWV, or IPPE visit furnished by a physician, NP, PA, or CNM was documented no more than one year prior to commencing psychiatric collaborative care services. This would be billed as an RHC or FQHC visit.
  • At least 70 minutes of psychiatric collaborative care model services are documented in the first calendar month
  • At least 60 minutes per month in subsequent months
  • Care team includes: RHC or FQHC practitioner (physician, NP, PA or CNM), behavioral health care manager and a psychiatric consultant
  • Services are provided under the direction of the RHC or FQHC physician, NP, PA or CNM
  • Services are provided by an RHC or FQHC practitioner or by behavioral health care manager under general supervision
  • Beneficiary consent is documented
  • Evidence of coordination of care between providers and the facilities used

Tips

  • Patient must have a behavioral health or psychiatric condition that is being treated by the RHC or FQHC practitioner, including substance use disorders, that, in the clinical judgment of the RHC or FQHC practitioner, warrants psychiatric collaborative care services
  • Billed once per month per beneficiary meeting time requirements
  • Must have a FQHC or RHC practitioner, behavioral health provider and psychiatric consultant

G9001, Coordinated care fee, initial assessment

Covered benefit under all plans, no member copay or deductible.

Documentation requirements

  • Date(s) of visit(s)
  • Appointment duration
  • Care manager name and credentials
  • Comprehensive patient assessment
  • Name of the caregiver and relationship to patient, if caregiver is included with the visit
  • Diagnoses discussed
  • Treatment plan, medication therapy, risk factors, unmet care, physical status, emotional status, community resources, readiness to change
  • Care plan, including challenges and interventions
  • Patient understanding and agreement with care plan
  • Physician coordination activities and approval of care plan
  • Name of member's PCP

Tips

  • Care provided by a QHP*
  • Initial care management assessment only
  • May be billed once annually for patients with ongoing care management
  • Must include a face-to-face visit with the patient
  • Work must encompass a minimum of 30 minutes, some of which may be without the patient present
  • Physicians may also bill G9008 if care meets billing and documentation requirements
  • Date of service = date the assessment was completed

G9002, Coordinated care fee, individual face-to-face visit

Covered benefit under all plans, no member copay or deductible.

Documentation requirements

  • Date(s) of visit(s)
  • Appointment duration
  • Care manager name and credentials
  • Name of the caregiver and relationship to patient, if caregiver is included with the visit
  • Diagnoses discussed
  • Treatment plan, self-management education, medication therapy, risk factors, unmet care, physical status, emotional status, community resources, readiness to change
  • Care plan update
  • Patient understanding and agreement with care plan
  • Physician coordination activities and approval of care plan
  • Name of member's PCP

Tips

  • Care provided by a QHP*
  • Must include a face-to-face visit with the patient
  • May include caregiver involvement
  • Focused discussion of the patient's care plan
  • Treatment plan, self-management education, medication therapy, risk factors, unmet care, physical status, emotional status, community resources, readiness to change
  • Ongoing care plan development
  • Code may be billed one time per day

G9007, Coordinated care fee, scheduled team conference

Covered benefit under all plans, no member copay or deductible.

Documentation requirements

  • Date(s) of conference(s)
  • Conference duration
  • Care team names and credentials
  • Diagnoses discussed
  • Treatment plan, self-management education, medication therapy, risk factors, unmet care, physical status, emotional status, community resources, readiness to change
  • Care plan updates
  • Physician coordination activities and approval of care plan

Tips

  • Scheduled care team meetings: physician, care manager and other QHPs*
  • Care provided by a physician
  • Patient is not present
  • Care plan developed, decisions documented
  • Self-management goals
  • Billed under physician's name
  • Code may be billed one time per day

G9008, Coordinated care fee, scheduled conference, physician oversight service

Covered benefit under all plans, no member copay or deductible.

Documentation requirements

  • Date(s) of visit
  • Appointment duration
  • Care team member names and credentials
  • Name of the caregiver and relationship to patient, if caregiver is included with the visit
  • Diagnoses discussed
  • Treatment plan, self-management education, medication therapy, risk factors, unmet care, physical status, emotional status, community resources, readiness to change
  • Preparation of shared care plan written by care manager
  • PCP approval of care plan
  • Patient understanding and agreement with care plan
  • Physician coordination activities and approval of care plan

Tips

  • Care must be provided by a physician.
  • Service must include patient face-to-face: Either face-to-face with PCP, patient and care manager, OR face-to-face with patient and care manager, with care manager/PCP direct involvement on a separate occasion.
  • Patient must formally agree to the care plan.
  • Service must include completion of patient assessment.
  • Bill code after the patient enrolls in a care management program.
  • A PCP evaluation and management visit must be billed in close proximity to this visit date.
  • G9001 or G9002 must also be billed in close proximity to this visit date.
  • This code may only be billed one time, per practice, during the time that patient is a member of the practice.

G9678, Oncology care model/MEOS payment

Covered benefit under all plans, only for providers with a specific written contract to provide this service. Non-contracted providers who bill this will result in denied claims. 

G9678 represents the monthly enhanced oncology services (MEOS) payment required by contract to participating providers. 

Tips:

MEOS can be billed once monthly by participating OCM practices only for patients meeting the Episode of Care criteria:

  • Patient must have a qualifying cancer diagnosis.
  • Patient must have a qualifying chemotherapy code.
  • The patient has at least one cancer-related Evaluation & Management (E&M) visit during the six- month episode, defined as HCPCS codes in the ranges 99201-99205 and 99211-99215.

98966, Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent or guardian, 5-10 minutes of medical discussion

Documentation requirements

  • Date(s) of contacts
  • Contact duration
  • Care team names and credentials
  • Diagnoses discussed
  • Development and/or maintenance of a shared care plan
  • Care team coordination activities
  • Names of providers contacted in the course of coordinating care
  • Discussion notes for each contact

Tips:

  • Care provided by a QHP
  • Non-face-to-face encounter initiated by an established patient or by the patient's guardian
  • Excludes decision to see the patient within 24 hours of the call
  • Excludes calls during the postoperative period of a procedure

98967, Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent or guardian, 11-20 minutes of medical discussion

Documentation requirements

  • Date(s) of contacts
  • Contact duration
  • Care team names and credentials
  • Diagnoses discussed
  • Development and/or maintenance of a shared care plan
  • Care team coordination activities
  • Names of providers contacted in the course of coordinating care
  • Discussion notes for each contact

Tips:

  • Care provided by a QHP
  • Non-face-to-face encounter initiated by an established patient or by the patient's guardian
  • Excludes decision to see the patient within 24 hours of the call
  • Excludes calls during the postoperative period of a procedure

98968, Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent or guardian, 21-30 minutes of medical discussion

Documentation requirements

  • Date(s) of contacts
  • Contact duration
  • Care team names and credentials
  • Diagnoses discussed
  • Development and/or maintenance of a shared care plan
  • Care team coordination activities
  • Names of providers contacted in the course of coordinating care
  • Discussion notes for each contact

Tips:

  • Care provided by a QHP
  • Non-face-to-face encounter initiated by an established patient or by the patient's guardian
  • Excludes decision to see the patient within 24 hours of the call
  • Excludes calls during the postoperative period of a procedure

99484 Care management services for behavioral health - At least 20 minutes of clinical staff time per calendar month.
Covered benefit under all plans, member copay and deductible apply.

Documentation requirements

  • Specific elements of a treatment plan must be provided and documented.
  • Documentation should include the initial assessment or follow-up monitoring involving the use of validated rating scales.
  • Documentation of behavioral health care planning (including revisions or status change).
  • Documentation of organizing/coordinating all aspects (therapy, medications, counseling, and/or psychiatric consultations).
  • Ongoing treatment with care management team member.
  • Clinical staff should be available to provide the patient with face-to-face services.
  • Time of services must be documented and meet minimum time requirements per month. 

99487, Complex chronic care coordination, first hour physician directed, no face-to-face visit, per calendar month

Covered benefit under all plans, member copay and deductible apply.

Documentation requirements

  • Date(s) of contacts
  • Contact duration
  • Care team names and credentials
  • Diagnoses discussed
  • Development and/or maintenance of a shared care plan
  • Care team coordination activities
  • Names of providers contacted in the course of coordinating care
  • Discussion notes for each contact

Tips

  • Care must be coordinated by a physician and the care team.
  • Patient does not need to be present for team conferences.
  • Patient contact may be by phone or face-to-face.
  • Includes coordination of services with health care community: Physicians, facilities, ancillary providers, community agencies, etc.
  • Note the cumulative services provided in one calendar month.
  • Cumulative time per patient must exceed 60 minutes.
  • Bill one unit per month for cumulative time of 60 minutes.
  • Billed date of service: Use the date on which services were last provided during the month.

99489, Add-on code to 99487, each additional 30 minutes

Covered benefit under all plans, member copay and deductible apply.

Documentation requirements

  • Date(s) of visit and/or contacts
  • Appointment or contact duration
  • Name of caregiver and relationship to patient, if caregiver is included with the visit
  • Care team names and credentials
  • Diagnoses discussed
  • Care team coordination activities
  • Names of providers contacted in the course of coordinating care
  • Discussion notes for each contact

Tips

  • Code should only be billed in cases where the cumulative time exceeds 90 minutes.
  • Care is coordinated by a physician and the care team
  • Patient does not need to be present for team conferences.
  • Add-on code to 99487
  • Multiple units may be billed
  • Billed date of service: Use the date on which services were last provided during the month.

99490, Chronic care management services

Not a covered benefit for group or individual commercial plans. Covered benefit under Medicare and Medicaid. Copay may apply.

Documentation requirements

  • Date(s) of visit(s) and/or contacts
  • Appointment or contact duration
  • Care team names and credentials
  • Diagnoses discussed
  • Care team coordination activities
  • Names of providers contacted in the course of coordinating care
  • Comprehensive care plan
  • Discussion notes for each contact
  • Development and/or maintenance of a shared care plan
  • As appropriate: Treatment plan, self-management education, medication therapy, visit factors, unmet care, physical status, emotional status, community resources, readiness to change

Tips

  • Management must take at least 20 minutes of staff time over the course of one month.
  • Work must be directed by a physician or qualified health professional.
  • Patients must have two or more chronic conditions that place them at a significant risk of death, acute exacerbation/decompensation, or functional decline.
  • Care plan must be implemented, revised or monitored during the course of care.

99492, Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of BHCM activities, in consultation with a psychiatric consultant, and directed by the treating physician or other QHP

Covered benefit under all plans, member copay and deductible apply.

Documentation requirements

  • Enter patient in a registry and track patient follow-up and progress
  • Initial assessment of the patient
  • Provision of brief interventions using evidence-based techniques
  • Appointment duration

Tips

  • Reported only by the treating physician or QHP, as the psychiatric consultant's services are included in these codes. The treating physician pays the psychiatric consultant through a contractual arrangement.
  • Time spent in PCCM activities while the patient is in observation or inpatient hospital status should not be included while reporting these services.
  • PCCM activities to coordinate care with the emergency department may be included in the time of service reported.
  • A new episode of care starts after a break in episode of six calendar months or more

99493, Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of BHCM activities, in consultation with a psychiatric consultant, and directed by the treating physician or other QHP

Covered benefit under all plans, member copay and deductible apply.

Documentation requirements

  • Track patient follow-up and progress using the registry
  • Appointment duration
  • Relapse prevention planning with patients as they achieve remission of symptoms
  • Additional review of progress and recommendations for changes in treatment

Tips

  • Reported only by the treating physician or QHP
  • Weekly conversations must occur

99494, Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of BHCM activities, in consultation with a psychiatric consultant, and directed by the treating physician or other QHP

Documentation requirements

  • Appointment duration

Tips

  • List separately in addition to code for primary procedure.
  • Use 99494 in conjunction with 99492, 99493

99495, Transitional care management: moderate complexity, patient contact within 2 business days of discharge and a face-to-face within 14 calendar days of discharge

Covered benefit under all plans, member copay and deductible apply.

Documentation requirements

  • Date of office visit
  • Date of phone visit
  • Diagnoses discussed
  • Refer to CPT Manual for additional documentation requirements.

Tips

  • Care is provided by a physician.
  • Code is intended to be used in place of an office-based evaluation and management service.
  • Patient contact must occur by phone within 2 business days of discharge. This call should include medication reconciliation.
  • An office visit within 14 calendar days of discharge is also required.
  • The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. The date of service you report should be the 30th day post-discharge. 
  • You may submit the claim on the 30th day post-discharge.
  • Search cms.gov for helpful reference materials regarding transitional care management services.

99496, Transitional care management: high complexity, patient contact within 2 business days of discharge and a face-to-face within 7 calendar days of discharge

Covered benefit under all plans, member copay and deductible apply.

Documentation requirements

  • Date of office visit
  • Date of phone visit
  • Diagnoses discussed
  • Refer to CPT Manual for additional documentation requirements.

Tips

  • Care is provided by a physician.
  • Code is intended to be used in place of an office-based evaluation and management service.
  • Patient contact must occur by phone within 2 business days of discharge. This call should include medication reconciliation.
  • An office visit within 7 calendar days of discharge is also required.
  • The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. The date of service you report should be the 30th day post-discharge. 
  • You should submit the claim on the 30th day post-discharge.
  • Search cms.gov for helpful reference materials regarding transitional care management services.

*QHPs include RNs, certified NPs, PA-Cs, licensed Master social workers (LMSWs), psychologists (LLPs and PhDs.), certified diabetic educators (CDEs), Registered Dieticians, Masters'-trained nutritionists, clinical pharmacists and respiratory therapists.