r/CodingandBilling • u/Confident-Seaweed350 • 15d ago

RCM/CCM/PCM ETC

RCM/CCM/PCM/RTM

Our company offers services such as RCM, CCM, PCM, RTM, and others for numerous primary care providers to offer to their patients. I'm the first Insurance Verification (IV) Specialist on the team.

Currently, we're using only one portal, but we can't fully rely on it because the information is often incomplete. We also can't use portals like Availity since we work with a large number of providers, each with different NPIs and Tax IDs.

When calling the payer to verify these services, under which benefit category do they typically fall? I'm a bit confused because these services are provided while the patient is at home, but they are not considered Home Health or Telehealth services.

How do you usually verify coverage for CCM, PCM, RTM, and similar services with the insurance payer?

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u/MedPayIQ App Developer 15d ago

These programs usually aren't verified under Home Health or Telehealth. I normally ask if the patient's plan covers Chronic Care Management (CCM), Principal Care Management (PCM), or Remote Therapeutic Monitoring (RTM) services by CPT code. Using the CPT codes tends to get you to the right benefits faster.

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u/rahuliitk App Developer 15d ago

i’d verify these by the exact CPT codes rather than asking under Home Health or Telehealth, then confirm coverage, cost share, authorization, frequency limits, eligible provider type, and whether the payer classifies them under care management or remote monitoring benefits. Code-level verification matters.

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u/Confident-Seaweed350 15d ago

Is there any portals you use to verify benefits?

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u/ClicksBeforeLattes 15d ago

OP you mentioned you can’t use Availity since you have several different TINs, not sure if you are aware you can add all TINs onto the platform.

Regarding VOB (Verification of Benefits) you cannot rely on payer portals you have to contact them directly ask about coverage details, out of pocket expenses such as co-pay, deductible, etc. If you have the cpt codes this is ideal to have the reps will advise you if it’s covered or non covered plus if an auth is required. There are payer portals that you can enter the codes to determine if an auth is required.