Provider-Delivered Care Management is an integral part of our Patient-Centered Medical Home model. PDCM practices deliver care management to chronic condition patients right in the office, where it is most convenient. Provider-Delivered Care Management is delivered by the physician working collaboratively with a care team.

The care team provides care that's personalized and focused on the whole patient. It may include nurses, social workers, nutritionists, certified diabetes educators, or pharmacists. Because these health care professionals are directly affiliated with the patient's primary care physician, services are integrated and coordinated.

All designated Patient-Centered Medical Homes are eligible to bill 12 distinct care management codes for delivering in-office care management services that may be telephonic, in-person, or in groups. In addition, practices that deliver care management services and meet other criteria as specified by Blue Cross may be eligible to receive value-based reimbursement for this enhanced care delivery model.