Which Patients Qualify for CCM, RPM, or TCM? Your Easy Eligibility Checklist

Story by Connor Danielowski / September 25, 2025

Determining whether a patient qualifies for Chronic Care Management (CCM), Remote Patient Monitoring (RPM), or Transitional Care Management (TCM) doesn’t need to be complicated. Each program has specific criteria, but when organized into a simple checklist, providers can quickly see where patients fit. This guide outlines the essentials and shows how these programs work together to improve outcomes and reduce hospitalizations.

Quick Refresher: CCM, RPM, and TCM

• CCM (Chronic Care Management): Designed for Medicare patients with two or more chronic conditions expected to last at least 12 months (or until death). Services focus on care coordination, medication management, and ongoing support. Learn more in our Chronic Care Management overview.
  
• RPM (Remote Patient Monitoring): Uses connected medical devices to track physiologic data such as blood pressure, weight, or glucose. Data is transmitted back to the provider for treatment decisions and care adjustments. Explore our Remote Patient Monitoring services. Learn More about RPM from CMS.gov.
  
• TCM (Transitional Care Management): Covers the critical 30 days after a patient is discharged from an inpatient setting, focusing on reducing readmissions and ensuring continuity of care. TCM often overlaps with CCM and RPM, creating a more complete model of value-based care. See how we tie this into value-based care programs.
  • View CMS.gov’s Transactional Care Management Services Booklet
    

Eligibility Checklist

Here’s a simple way to evaluate patient eligibility:

Chronic Care Management (CCM)

• Patient has two or more chronic conditions expected to last at least 12 months.
  
• Conditions pose a significant risk of exacerbation or functional decline.
  
• Patient provides consent to participate.
  
• Requires a comprehensive care plan and monthly management.
  → For deeper insights, see our blog on RPM vs. CCM: 5 Key Differences Explained.
  

Remote Patient Monitoring (RPM)

• Patient has a chronic or acute condition that can benefit from connected device tracking.
  
• An established provider relationship is required prior to enrollment.
  
• Device must capture and transmit physiologic data (blood pressure, weight, oxygen, etc.).
  
• Data should be collected over 16+ days within 30 days to bill for monitoring.
  
• Provider must review and act on the transmitted data each month.
  → Learn how RPM can be seamlessly integrated into workflows in our CCM + RPM integration guide.
• View ALL Remote Patient Monitoring (RPM) Documentation Requirements here
  

Transitional Care Management (TCM)

• Patient has been discharged from a hospital, SNF, or other inpatient facility.
  
• Provider must make interactive contact within 2 business days post-discharge.
  
• Requires a face-to-face visit within 7 or 14 days depending on case complexity.
  
• Ongoing management is provided during the 30-day transition period.
  → For regulatory updates impacting TCM, see our summary of the CMS 2026 Proposed Rule.
  

Common Scenarios

• CCM: A diabetic patient with hypertension who needs consistent medication management and care coordination.
  
• RPM: A heart failure patient using a connected scale to monitor daily weight fluctuations.
  
• TCM: A patient discharged after pneumonia requiring close follow-up, medication reconciliation, and readmission prevention.
  

Why Eligibility Matters

Getting eligibility right isn’t just about reimbursement—it’s about ensuring patients receive the right level of support. The correct program:

• Reduces hospitalizations and ER visits.
  
• Improves patient engagement and outcomes.
  
• Positions practices for success in value-based care models.
  

Final Checklist for Providers

• Medicare Part B beneficiary
  
• Patient consent obtained
  
• Meets chronic condition or post-discharge requirements
  
• Documentation supports medical necessity
  
• Follow-up visits and data thresholds are met
  

Next Steps

Choosing the right care model can transform patient outcomes while strengthening compliance and reimbursement. If you’re unsure where to start, our team at Chronic Care Staffing can help you design and implement programs that align with CMS guidelines and your workflow.

Contact us today to learn how to launch or expand CCM, RPM, or TCM services in your organization.

Categories: Chronic Care Management News