[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-detail-168909-en":3,"doc-seo-168909-105":29,"detail-sidebar-cat-1-en-105":89},{"code":4,"msg":5,"data":6},0,"success",{"doc_id":7,"user_id":8,"nickname":9,"user_avatar":10,"doc_module":11,"category_id":12,"category_name":13,"doc_title":14,"doc_description":15,"doc_content":16,"file_id":17,"file_url":18,"file_type":19,"file_size":20,"view_count":4,"is_deleted":4,"is_public":11,"is_downloadable":11,"audit_status":11,"page_count":21,"language":22,"language_code":23,"site_id":24,"html_lang":23,"table_of_contents":25,"faqs":26,"seo_title":27,"seo_description":15,"update_tm":28,"read_time":11},168909,3848291630094,"Emma Wilson","https://eur-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45",1,17,"Forms","Chronic Care Management (CCM) Documentation - Workflow Checklist","Chronic Care Management (CCM) documentation template capturing core patient identifiers, insurance and ACO attribution details, and key care management inputs such as chronic diagnoses, last Medicare Wellness Visit date, and preferred pharmacy. Includes a CCM workflow checklist covering enrollment with welcome/anniversary letters, provider review of problem lists, care plan creation and distribution, referrals and prior authorizations, medication reconciliation, hospital transition follow-up, quality monitoring with lab review and patient contact, and continuation of care through external record collection.","Chronic Care Management (CCM) Documentation\nInsurance Provider: ___________________________\nPatient Name: ___________________________\nDate of Birth: ___________________________\nChronic Diagnosis(es): ___________________________\nDate of Last Medicare Wellness Visit (MWV): ____ / ____\nPreferred Pharmacy: ___________________________\nAttributed to ACO: Yes or No\nCCM Workflow Checklist\nPlease check each item as completed:\n☐ CCM Enrollment - Send Welcome Letter and Annual Anniversary Letter\n☐ Provider Review - Ensure provider has reviewed and approved the problem list.\n☐ Care Plan Review & Distribution - Review with patient and mail a copy of the care plan\n☐ Referrals & Prior Authorizations - Follow up on referrals\u000b   - Manage medication and diagnostic imaging prior authorizations\n☐ Care Plan Creation - Develop and document care plan (minimum twice per year via phone call)\n☐ Care Plan Review & Distribution - Review with patient and mail a copy of the care plan\n☐ Gaps in Care Review - Conduct review one month prior to the Annual Wellness Visit\n☐ Medication Reconciliation - Complete three times per year for high-risk patients\u000b   - May be conducted via phone (with pharmacy or patient) or in person\u000b   - Include all prescribed and over-the-counter medications\n☐ Hospital Transition of Care - Immediate follow-up required post-discharge\u000b   - Send Hospital Discharge Care Plan\n☐ Quality Care Monitoring - Review lab results and maintain regular patient contact (Diabetic education, reviewing blood sugar logs or blood pressure log with patient)\n☐ Continuation of Care - Obtain external records (e.g., imaging, consult notes) via call or print","cbCaiuvSNjHe6UuT","https://ap.wps.com/l/cbCaiuvSNjHe6UuT","docx",27735,2,"English","en",105,"# CCM Workflow Checklist\n## Patient & Insurance Details\n## Enrollment & Provider Review\n## Care Plan & Referrals\n## Medication Reconciliation & Transitions\n## Quality Monitoring & Continuation","[{\"question\":\"What patient and administrative fields are included in the CCM documentation template?\",\"answer\":\"The template collects insurance provider, patient name, date of birth, chronic diagnosis(es), date of last Medicare Wellness Visit, preferred pharmacy, and whether attributed to an ACO.\"},{\"question\":\"How often is the care plan created and reviewed according to the workflow checklist?\",\"answer\":\"The workflow specifies care plan creation at least twice per year via phone call, with care plan review and distribution through review with the patient and mailing a copy.\"},{\"question\":\"What steps are required after hospital discharge in the CCM workflow?\",\"answer\":\"Immediate post-discharge follow-up is required, including sending the hospital discharge care plan.\"}]","Chronic Care Management (CCM) Documentation - 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