Heart of An Angel Nursing Solutions LLC

Chronic Care Management Built Around You

A Medicare-covered program providing personalized monthly nursing support for patients with multiple chronic conditions — and a seamless partnership for referring physicians.

Enroll as a Patient Physician Referral Partners
The Program

What is Chronic Care Management?

CCM is a Medicare-reimbursed program dedicated to patients managing two or more chronic conditions — bringing care coordination directly to them between office visits.

Chronic Care Management (CCM) is a federally recognized Medicare program (CPT 99490/99491) designed for individuals living with two or more chronic health conditions expected to last 12 months or more, or until death.

Through CCM, Heart of An Angel Nursing Solutions provides ongoing monthly support — helping patients navigate their health, stay connected with their care team, and manage their conditions between physician visits.

The program includes at least 20 minutes of dedicated clinical staff time per calendar month focused on coordinating your care, updating your care plan, and making sure nothing falls through the cracks.

20+
Minutes of dedicated nursing time every month
$0*
Out-of-pocket cost for most Medicare beneficiaries

*Most patients pay $0 after Medicare covers the program. Your cost may vary based on supplemental coverage.

Do You Qualify?

2 or more chronic conditions — such as diabetes, hypertension, heart disease, COPD, or arthritis
Active Medicare Part B — must be an enrolled Medicare beneficiary
Ongoing conditions — lasting 12+ months or until end of life
Willing to consent — verbal or written consent is required to enroll
In our service area — Conyers, GA and surrounding communities
What's Included

Your Monthly CCM Services

Every enrolled patient receives a comprehensive package of care coordination services each month.

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Personalized written care plan, updated regularly
📞
Monthly nursing check-in calls or video visits
💊
Medication reconciliation and management review
🔗
Coordination across all of your treating physicians
📍
Specialist and community resource referrals
🕐
24/7 access to your dedicated care team
Patient Information

CCM Benefits for Patients

You manage your health every day — we're here to make it easier, more coordinated, and fully supported between your doctor visits.

✓
Covered by Medicare Part BMost patients pay little to nothing out of pocket

How CCM Helps You

A dedicated licensed nurse who knows your full health picture — not just one condition
Monthly check-in calls to monitor your conditions, medications, and overall well-being
A written, personalized care plan shared with all of your providers
Help scheduling specialist appointments and navigating referrals
Medication review to catch dangerous interactions before they become a problem
24/7 access to your care team for urgent questions between appointments
Connection to community resources, transportation, and social support

Qualifying Conditions

You may qualify if you have two or more of the following chronic conditions:

Qualifying conditions include:

Diabetes Hypertension Heart Disease COPD Heart Failure Arthritis Chronic Kidney Disease Depression Obesity Asthma Atrial Fibrillation Alzheimer's / Dementia Stroke History Cancer (ongoing) And more...

How to Get Started

  1. Complete the enrollment form — takes less than 3 minutes
  2. Our care team contacts you within 1 business day
  3. We confirm eligibility and obtain your consent
  4. Your care plan is created within 30 days
  5. Monthly care management begins right away
Physician Partnership

CCM for Referring Physicians & Practices

Partner with Heart of An Angel to expand your chronic care offering, improve patient outcomes, and capture additional Medicare revenue — with zero added documentation burden on your practice.

Why Partner With Us

Generate additional Medicare revenue per enrolled patient each month (CPT 99490, 99491, 99487)
Improve HEDIS quality measures, chronic disease management scores, and patient satisfaction ratings
Reduce avoidable emergency visits and hospital readmissions among your chronic care patients
We handle all CCM documentation, care plan management, and monthly coordination calls
You retain the primary physician-patient care relationship at all times
Receive regular care coordination summaries to keep your practice fully informed
Medicare CCM Revenue Opportunity
~$62–$130
Per enrolled patient, per month · CPT 99490/99491 · Varies by time and complexity

How Patient Capture Works

  1. Identify eligible patients — Review your Medicare panel for patients with 2+ qualifying chronic conditions. We can assist with identification.
  2. Submit a referral — Use our simple referral form or call 877-423-2420. No lengthy paperwork required.
  3. We contact the patient — Our licensed nursing staff reaches out, explains the program, and obtains informed consent.
  4. Care plan created in 30 days — A comprehensive, individualized care plan is developed and shared with your practice.
  5. Monthly management begins — We handle all monthly contact, documentation, and care coordination.
  6. You receive monthly reports — Regular summaries keep you informed on each patient's care status.

Ready to discuss a referral partnership?

Email Us 877-423-2420
Enroll Now

Request CCM Enrollment

Complete the form below and a member of our CCM care team will contact you within 1 business day.

✓ Medicare Part B covered
✓ 2+ chronic conditions required
✓ No obligation to enroll

Your information is protected under HIPAA. A member of our team will contact you within 1 business day.  ·  877-423-2420