Allergy & Immunology Chronic Care Enrollment Checklist

Identify patients with persistent asthma using GINA guidelines who require daily controller medications and periodic action plan updates.

Screen patients on subcutaneous (SCIT) or sublingual (SLIT) immunotherapy who have reached maintenance phase and require long-term monitoring.

Flag patients with chronic spontaneous urticaria requiring biologics like omalizumab for ongoing symptom management and flare prevention.

Identify PID patients receiving IVIG or SCIG who require monthly coordination of supplies and laboratory monitoring.

Select patients on systemic therapies or biologics for eczema who need regular assessment of skin barrier function and medication adherence.

Document patient agreement for CCM/PCM services, ensuring they understand the 24/7 access requirement and potential cost-sharing.

Use AI voice agents to reach out to eligible patients, explain program benefits, and capture recorded verbal consent for EHR integration.

Update the patient's chart with a specific 'Chronic Care' tag to ensure all clinical staff are aware of the enrollment status.

Provide patients with digital or physical copies of their allergy action plans and CCM program expectations.

Clearly communicate how the program interacts with their specific insurance plan, including deductible and co-pay information.

Conduct a comprehensive review of inhalers, antihistamines, biologics, and epinephrine auto-injectors currently prescribed.

Ensure every enrolled asthma patient has a current, personalized action plan detailing green, yellow, and red zone instructions.

Confirm the patient’s injection or dosing schedule and establish protocols for missed doses or systemic reactions.

Document specific environmental, food, or drug triggers to be monitored during monthly check-in calls.

Establish measurable outcomes such as reduced rescue inhaler use or improved ACT (Asthma Control Test) scores.

Deploy AI call agents to conduct monthly 20-minute clinical check-ins focused on asthma control and medication adherence.

Use automated prompts to remind patients to review proper inhaler or auto-injector technique via secure video links.

Set up AI-driven alerts for biologic refills or immunotherapy vial re-orders to prevent gaps in treatment.

Configure AI voice systems to recognize high-risk keywords like 'shortness of breath' and immediately escalate to clinical staff.

Ensure all AI-captured patient responses are automatically transcribed and structured into the clinical notes for billing.

Verify that at least 20 minutes of non-face-to-face clinical time was documented for the calendar month for CCM billing.

Ensure the correct Principal Care Management codes (99424-99427) are used for single-condition specialty management.

Confirm the practice has a documented pathway for patients to reach a clinician after hours, a core CCM requirement.

Have a provider or qualified staff member sign off on the monthly care coordination summary before claim submission.

Schedule a comprehensive annual review of the chronic care plan to maintain program eligibility and clinical relevance.