Sobia Care runs the monthly Chronic Care Management workflow as an extension of your team, while your practice keeps the patient relationship, clinical oversight, and billing.
Your medical assistants already have a full workload. CCM adds recurring outreach, documentation, coordination, and time tracking every month.
CCM creates recurring monthly reimbursement from eligible care-management services, without another in-office visit for every patient. Slide to estimate.
Your practice retains control of billing and reimbursement. Sobia Care manages the recurring workflow that supports it.
| CPT | Service | Time |
|---|---|---|
| 99490 | Clinical staff CCM | First 20 min / month |
| 99439 | Additional clinical staff CCM | Each added 20 min |
| 99491 | Physician / QHP CCM | First 30 min / month |
| 99437 | Additional physician / QHP CCM | Each added 30 min |
Six recurring parts of CCM, run as one coordinated monthly workflow inside your existing systems.
Candidate identification, the practice-approved consent workflow, patient preferences, and activation into the monthly program.
Care-plan priorities, goals, patient-reported information, and ongoing updates organized for practitioner review.
Dedicated monthly calls and follow-up that keep enrolled patients connected to their ongoing care.
Follow-up across medications, specialists, appointments, care gaps, and other needs identified during CCM interactions.
CCM interactions and qualifying time documented in the practice's existing workflow.
Issues requiring clinical judgment escalated; completed monthly activity organized for provider review and billing.
We learn your EHR, documentation, enrollment, escalation, and billing workflow.
Your practice identifies eligible candidates, or we prepare a list for practitioner review.
Approved patients move through your consent and activation process.
Your dedicated specialist handles outreach, coordination, documentation, and time tracking.
Providers stay informed and receive items requiring clinical review.
Your billing team receives organized, billing-ready monthly documentation.
A consistent point of contact who learns your providers, patients, documentation preferences, and escalation protocols.
We adapt to your EHR, documentation standards, escalation preferences, and billing process.
A clear line for patient status, documentation questions, workflow concerns, and escalations.
Enrollment, outreach progress, documented time, unresolved needs, and billing readiness, always in view.
Sobia Care was built from hands-on experience supporting Chronic Care Management inside a medical practice: patient enrollment, care-plan workflows, monthly outreach, documentation, time tracking, care coordination, and provider follow-up.
The model was designed around a simple question: how do we make CCM easier for the practice without disconnecting the physician from the patient's care?
We are intentionally building around smaller, more focused partnerships, so your team is never one account among hundreds.
A 20-minute look at your patient population, current workflow, and EHR. No commitment, no prep needed on your end.
Tell us about your patient population and current workflow. Please don't include patient or protected health information.