CCM services
-- at least 20 minutes of clinical staff time directed by a physician
or other qualified healthcare professional, per calendar month,
with the following required elements:
• Multiple
(two or more) chronic conditions expected to last at least 12 months
or until death of the patient;
• Chronic
conditions place the patient at significant risk of death, acute
exacerbation/decompensation, or functional decline; and
• Comprehensive
care plan established, implemented, revised, or monitored.