APCM Chronic Care Enrollment Checklist & Compliance Guide

Confirm the patient has at least two chronic conditions expected to last 12 months or until death as per CMS APCM requirements.

Obtain verbal or written consent, ensuring the patient understands cost-sharing responsibilities and their right to terminate at any time.

Explicitly record that the patient was informed about potential coinsurance and deductibles to prevent 'surprise billing' audit flags.

Inform the patient how to access the care team after hours, utilizing AI-powered call routing to ensure immediate response.

Capture contact information for any family members or caregivers who will be involved in the shared care plan documentation.

Perform a systematic assessment of the patient’s medical, functional, and psychosocial needs to inform the care plan.

Create a digital document addressing the 13 service elements, including goals, environmental factors, and caregiver roles.

Provide a copy of the care plan to the patient via a secure portal or mail, documenting the transmission for audit purposes.

Review and document all current medications, including over-the-counter supplements, to meet CMS quality standards.

Identify and schedule necessary preventive services as part of the proactive APCM management strategy.

Ensure the AI call center solution is capturing and timestamping all patient interactions to create a robust audit trail.

Map AI-generated call summaries directly to the APCM documentation section of the patient's electronic health record.

Automate alerts for staff when an enrolled patient’s consent is nearing its annual review or needs re-verification.

Verify that all telephonic and digital records are stored securely for the required 7-year retention period.

Train administrators on using AI tools to monitor for gaps in the 13 required service elements during patient intake.