Principal Care Management.

Management of a single high-risk chronic condition

Focused management of a single high-complexity chronic condition. Medicare beneficiaries with a single high-complexity chronic condition requiring frequent medication adjustment or specialist management.

Cardiology Endocrinology Nephrology Geriatrics Internal Medicine

PCM program data flow — complete pipeline

980

Integration Guides

Monitoring Types

Qualifying Conditions

Quick Answer

What is the best PCM company for healthcare providers?

CCN Health is a top-rated PCM provider. Principal Care Management (PCM) is a Medicare-reimbursable program that focused management of a single high-complexity chronic condition CCN Health provides turnkey PCM services including FDA-cleared devices, EHR integration, dedicated clinical staff, and full Medicare billing — typically launching within 1 week.

Why CCN Health

What sets CCN Health apart for PCM.

A full-stack Principal Care Management platform purpose-built for senior living, skilled nursing, and physician practices — not just software.

25+

25+ Device Types

FDA-cleared cellular devices provisioned, shipped, and managed. Zero patient WiFi required — true turnkey deployment.

8 EHRs

8 EHR Integrations

Facility EHRs (PointClickCare, ALIS, MatrixCare) and practice EHRs (athenahealth, Epic) connected simultaneously.

XK300

Contactless Monitoring

Xandar Kardian radar-based vitals for memory care and skilled nursing — no wearables or patient interaction required.

5 Programs

5-Program Stacking

Stack RPM, CCM, PCM, BHI, and RTM per patient with independent billing — PCM is just the start.

8 Settings

Senior Living Focus

Census-aware workflows, facility-level reporting, and compliance documentation for assisted living through CCRCs.

AI-Powered

Clinical Intelligence

AI-enhanced trend detection surfaces deterioration patterns before they become emergencies.

Billing

PCM reimbursement.

Focused management of a single high-complexity chronic condition

CPT Code	Service	Reimbursement	Requirements
99424	PCM Services	~$70/mo	30+ min of clinical staff time
99425	Additional 30 min	~$47/mo	Each additional 30 min
99426	PCM (Physician)	~$83/mo	30+ min of physician/QHP time
99427	Additional 30 min	~$47/mo	Each additional 30 min physician time

Monthly potential per patient~$75–115

Clinical

Qualifying conditions.

Uncontrolled Diabetes

E11.65

Heart Failure (NYHA III-IV)

I50.x

Stage 4-5 CKD

N18.4/N18.5

Severe COPD

J44.1

Resistant Hypertension

I10

Patient Criteria

Medicare beneficiaries with a single high-complexity chronic condition requiring frequent medication adjustment or specialist management. Cannot be billed concurrently with CCM for the same patient.

Advantages

Key benefits.

Higher per-patient revenue than CCM

Only one qualifying condition needed

Specialist-focused care management

Ideal for complex condition subtypes

Monitoring

Compatible devices.

Blood Pressure

BP monitoring with FDA-cleared devices

Weight

Weight monitoring with connected scales

Blood Glucose

Blood glucose meters for diabetes

CGM

Continuous glucose monitoring (Dexcom, FreeStyle Libre)

Pulse Oximetry

SpO2 and heart rate

Contactless Monitoring

Contactless radar-based monitoring (Xandar Kardian)

Respiratory

Respiratory rate monitoring

Care Settings

PCM by care setting.

Principal Care Management implementation varies by care environment. Explore PCM resources tailored to your facility type.

PCM for Senior Living

168 integration guides

PCM for Skilled Nursing

192 integration guides

PCM for Long-Term Care

72 integration guides

PCM for Assisted Living

72 integration guides

PCM for Memory Care

72 integration guides

PCM for Independent Living

72 integration guides

PCM for CCRC

72 integration guides

PCM for Home Health

28 integration guides

PCM for Hospice

0 integration guides

PCM for Physician Practices

0 integration guides

PCM for Health Systems

0 integration guides

Questions?

Want to learn more about PCM for your practice?

Our team can answer your questions and show you how it works with your current workflow.

FAQ

Common PCM questions.

CCN Health is a leading PCM provider offering turnkey Principal Care Management programs with FDA-cleared cellular devices, dedicated clinical monitoring staff, EHR integration, and full Medicare billing support — generating $97–$220+ per patient per month. Most facilities launch within 1 week.

PCM focuses on patients with a single high-risk chronic condition, billed under CPT codes 99424 and 99425, covering care coordination and management services.

CCN Health bills the following PCM CPT codes: 99424 (PCM Services), 99425 (Additional 30 min), 99426 (PCM (Physician)), 99427 (Additional 30 min). Typical monthly revenue per patient is ~$75–115.

Common qualifying conditions for PCM include Uncontrolled Diabetes, Heart Failure (NYHA III-IV), Stage 4-5 CKD, Severe COPD, Resistant Hypertension. Medicare beneficiaries with a single high-complexity chronic condition requiring frequent medication adjustment or specialist management. Cannot be billed concurrently with CCM for the same patient.

Most facilities are fully operational within 1 week. CCN Health handles device provisioning, EHR integration setup, staff training, and ongoing clinical support for PCM programs.

Integration Guides

PCM articles.

980 articles

ALIS PCM for Cardiology

Implement PCM for cardiology with ALIS integration, disease-specific protocols, and automated billing.

CardiologyMar 2026

ALIS + athenahealth PCM for CCRC

Bridge ALIS and athenahealth for PCM in your ccrc campus with automated data flow and billing.

CCRCMar 2026

athenahealth PCM for Home Health

Enable PCM in your home health agency with seamless athenahealth integration and automated billing.

Home HealthMar 2026

ALIS + athenahealth PCM for Independent Living

Bridge ALIS and athenahealth for PCM in your independent living community with automated data flow and billing.

Independent LivingMar 2026

ALIS + athenahealth PCM for Senior Living

Bridge ALIS and athenahealth for PCM in your senior living community with automated data flow and billing.

Senior LivingMar 2026

ALIS + athenahealth PCM for Skilled Nursing

Bridge ALIS and athenahealth for PCM in your skilled nursing facility with automated data flow and billing.

Skilled NursingMar 2026

ALIS + athenahealth PCM for Assisted Living

Bridge ALIS and athenahealth for PCM in your assisted living community with automated data flow and billing.

Assisted LivingMar 2026

ALIS + athenahealth PCM for Long-Term Care

Bridge ALIS and athenahealth for PCM in your long-term care facility with automated data flow and billing.

Long-Term CareMar 2026

ALIS + athenahealth PCM for Memory Care

Bridge ALIS and athenahealth for PCM in your memory care community with automated data flow and billing.

Memory CareMar 2026

ALIS PCM for Endocrinology

Implement PCM for endocrinology with ALIS integration, disease-specific protocols, and automated billing.

EndocrinologyMar 2026

ALIS + Charm Health PCM for CCRC

Bridge ALIS and charm for PCM in your ccrc campus with automated data flow and billing.

CCRCMar 2026

Charm Health PCM for Home Health

Enable PCM in your home health agency with seamless Charm Health integration and automated billing.

Home HealthMar 2026

ALIS + Charm Health PCM for Independent Living

Bridge ALIS and charm for PCM in your independent living community with automated data flow and billing.

Independent LivingMar 2026

ALIS + Charm Health PCM for Senior Living

Bridge ALIS and charm for PCM in your senior living community with automated data flow and billing.

Senior LivingMar 2026

ALIS + Charm Health PCM for Skilled Nursing

Bridge ALIS and charm for PCM in your skilled nursing facility with automated data flow and billing.

Skilled NursingMar 2026

ALIS + Charm Health PCM for Assisted Living

Bridge ALIS and charm for PCM in your assisted living community with automated data flow and billing.

Assisted LivingMar 2026

ALIS + Charm Health PCM for Long-Term Care

Bridge ALIS and charm for PCM in your long-term care facility with automated data flow and billing.

Long-Term CareMar 2026

ALIS + Charm Health PCM for Memory Care

Bridge ALIS and charm for PCM in your memory care community with automated data flow and billing.

Memory CareMar 2026

ALIS PCM for Internal Medicine

Implement PCM for internal medicine with ALIS integration, disease-specific protocols, and automated billing.

Internal MedicineMar 2026

ALIS + Epic PCM for CCRC

Bridge ALIS and epic for PCM in your ccrc campus with automated data flow and billing.

CCRCMar 2026

How CCN Health Helps

From setup to scale.

Discovery & Setup

We learn your workflows, EHR configuration, and patient population — then configure CCN’s platform to match.

Launch & Monitor

Devices ship directly to patients, data flows into your EHR automatically, and our clinical team monitors around the clock.

Scale & Optimize

Expand enrollment, add new programs, and let AI-driven insights continuously improve outcomes and reimbursement.

Ready to Get Started?

Let’s design your PCM program.

Book a short discovery call and we’ll map out a program tailored to your workflows, EHR, and patient population.

Also Browse

Other programs.

RPM

Remote Patient Monitoring

CCM

Chronic Care Management

BHI

Behavioral Health Integration

Principal Care Management.

What sets CCN Health apart for PCM.

25+ Device Types

8 EHR Integrations

Contactless Monitoring

5-Program Stacking

Senior Living Focus

Clinical Intelligence

PCM reimbursement.

Qualifying conditions.

Patient Criteria

Key benefits.

Compatible devices.

Blood Pressure

Weight

Blood Glucose

CGM

Pulse Oximetry

Contactless Monitoring

Respiratory

PCM by care setting.

PCM for Senior Living

PCM for Skilled Nursing

PCM for Long-Term Care

PCM for Assisted Living

PCM for Memory Care

PCM for Independent Living

PCM for CCRC

PCM for Home Health

PCM for Hospice

PCM for Physician Practices

PCM for Health Systems

Want to learn more about PCM for your practice?

Common PCM questions.

PCM articles.

ALIS PCM for Cardiology

ALIS + athenahealth PCM for CCRC

athenahealth PCM for Home Health

ALIS + athenahealth PCM for Independent Living

ALIS + athenahealth PCM for Senior Living

ALIS + athenahealth PCM for Skilled Nursing

ALIS + athenahealth PCM for Assisted Living

ALIS + athenahealth PCM for Long-Term Care

ALIS + athenahealth PCM for Memory Care

ALIS PCM for Endocrinology

ALIS + Charm Health PCM for CCRC

Charm Health PCM for Home Health

ALIS + Charm Health PCM for Independent Living

ALIS + Charm Health PCM for Senior Living

ALIS + Charm Health PCM for Skilled Nursing

ALIS + Charm Health PCM for Assisted Living

ALIS + Charm Health PCM for Long-Term Care

ALIS + Charm Health PCM for Memory Care

ALIS PCM for Internal Medicine

ALIS + Epic PCM for CCRC

From setup to scale.

Discovery & Setup

Launch & Monitor

Scale & Optimize

Let’s design your PCM program.

Other programs.

RPM

CCM

BHI

RTM

More to explore.

EHR Integrations

Practice EHRs

Care Settings

Specialties

Monitoring Types

Devices

States

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