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.