One platform for value-based care: billable, time-tracked care-management programs; risk-adjustment & revenue capture; payer interoperability; and US regulatory compliance — deployed as the commvita Care ACO jurisdiction on a CMS MSSP Enhanced Track, with MBI + MRN identifiers (no SSN stored) and USD throughout.
commvita Care ACO turns on the US module pack: the care-management programs that generate revenue and quality, the risk & quality surfaces that capture and defend it, and the payer/compliance rails that move it. Each pillar maps to real routes in the platform.
Longitudinal programs with per-patient time capture against CPT/HCPCS and threshold logic — CCM (≥20 min/mo), BHI/CoCM, Transitional Care, Principal Care, Annual Wellness Visit, RPM (≥16 days), RTM and Readmission Prevention (HRRP).
Close CMS-HCC v28 gaps, defend RAF against undercoding, track total cost of care vs CMS benchmark (MSSP), and report HEDIS / STARS / ACO-11 — plus STAR ratings, episodes, leakage and SDOH.
Move data with payers — Prior Auth (CMS-0057-F, Da Vinci PAS), DTR, dHEDIS and X12 EDI feeds — and satisfy the CMS/ONC rulebook: No Surprises Act, CMS Interoperability, Cures Act, Conditions of Participation, TEFCA/QHIN.
Every care-management program captures clinical work as time against a CPT/HCPCS code and enforces the CMS billing threshold, so a month of care becomes a defensible claim. These programs are Live — API-backed today.
Registry, per-patient time tracking and billing against 99490 99491 99439, with care plans and the ≥20-minute monthly threshold enforced before a claim is marked ready.
Behavioral-health integration with a PHQ-9 / GAD-7 registry, weekly psychiatric review and trend charts (99492 99493 99494); Principal Care Management for a single high-complexity condition (99424 99425).
Post-discharge Transitional Care (99495 99496) with a 30-day readmission lens; Annual Wellness Visit with HRA & screening and billing to G0438 G0439.
Remote Patient Monitoring with device enrollment, live readings and the ≥16-day billing threshold (99453 99454 99457 99458); Remote Therapeutic Monitoring for MSK / respiratory / behavioral programs (98975–98981); plus HRRP-focused Readmission Prevention.
Value-based revenue depends on accurate risk adjustment and closed quality gaps. commvita surfaces the gap, quantifies the uplift, and produces the CMS submission — demonstrated on seeded data.
CMS-HCC v28 gap closure per patient in HCC Risk Coding; RAF Score Monitor trends the score and flags undercoding, while RAF Recapture mines notes to surface revenue uplift by ICD-10 code.
The TCOC Dashboard tracks spend vs CMS benchmark, the 3-year trend and gross savings / loss — the core shared-savings calculation for an MSSP ACO.
Quality Measure Tracker composites HEDIS / STARS / ACO-11 with gap closure; STAR Ratings optimizes Medicare Advantage Part C/D; and QRDA I/III produces the CMS eCQM submission (patient-level & aggregate).
Episode Analytics on BPCI 90-day bundles, Network Leakage Alerts on out-of-network referrals, and SDOH Screening capturing AHC HRSN domains → Z-codes for social-risk documentation.
The rails that move authorizations, quality and claims between provider and payer — and the CMS/ONC rulebook the ACO must satisfy. Demonstrated control surfaces over the real payer standards.
FHIR-based prior-auth submission and status tracking against CMS-0057-F via Da Vinci PAS, with Da Vinci DTR pre-filling payer FHIR Questionnaires from the patient record.
Payer Dashboard and Payer Data Feeds move dHEDIS quality reporting and X12 EDI 837 / 835 / 270 / 271 claims & eligibility; ACO Attribution rolls up CMS prospective/retrospective attribution (42 CFR 425).
No Surprises Act Good Faith Estimates (42 CFR §149), CMS Interoperability Patient Access FHIR API (CMS-9115-F), 21st Century Cures Act information-blocking (ONC 45 CFR §170) and CMS Conditions of Participation (42 CFR Part 482) each have a dedicated surface.
TEFCA / QHIN exchange for nationwide interoperability — XCPD patient discovery, XCA document query/retrieve and FHIR responder endpoints against TEFCA v1.1 · ONC HTI-1 · US Core v6.
| Capability | Module | Route | Standard / codes | Status |
|---|---|---|---|---|
| Chronic Care Management | CCM | /ccm | CPT 99490/99491/99439 · ≥20 min/mo | ● Live |
| Collaborative Care (BHI/CoCM) | Collaborative Care | /collaborative-care | PHQ-9/GAD-7 · CPT 99492/99493/99494 | ● Live |
| Transitional Care | Transitional Care | /transitional-care | CPT 99495/99496 · 30-day readmit | ● Live |
| Principal Care Management | PCM | /pcm | CPT 99424/99425 · ≥30 min/mo | ● Live |
| Annual Wellness Visit | AWV | /awv | HCPCS G0438/G0439 · HRA | ● Live |
| Remote Patient Monitoring | RPM | /rpm | CPT 99453/99454/99457/99458 · ≥16 days | ● Live |
| Remote Therapeutic Monitoring | RTM | /rtm | CPT 98975–98981 | ● Live |
| Readmission Prevention | Readmission Prevention | /readmission-prevention | CMS HRRP | ◍ Demonstrated |
| HCC risk coding | HCC Risk Coding | /hcc-risk-coding | CMS-HCC v28 gap closure | ◍ Demonstrated |
| RAF monitor & recapture | RAF Score Monitor · RAF Recapture | /raf-score-monitor · /raf-recapture | undercoding → uplift by ICD-10 | ◍ Demonstrated |
| Total cost of care (MSSP) | TCOC Dashboard | /tcoc-dashboard | spend vs CMS benchmark · 3-yr trend | ◍ Demonstrated |
| Quality measures & STARS | Quality Measure Tracker · STAR Ratings · QRDA | /quality-measure-tracker · /star-ratings · /qrda-reporting | HEDIS/STARS/ACO-11 · CMS eCQM | ◍ Demonstrated |
| Episodes · leakage · SDOH | Episode Analytics · Network Leakage · SDOH Screening | /episode-analytics · /network-leakage · /sdoh-screening | BPCI 90-day · AHC HRSN Z-codes | ◍ Demonstrated |
| Prior auth & DTR | Prior Auth · Da Vinci DTR | /prior-auth · /davinci-dtr | CMS-0057-F · Da Vinci PAS/DTR | ◍ Demonstrated |
| Payer feeds & attribution | Payer Dashboard · Payer Data Feeds · ACO Attribution | /payer-dashboard · /payer-data-feeds · /aco-attribution | dHEDIS · X12 EDI 837/835/270/271 · 42 CFR 425 | ◍ Demonstrated |
| US compliance rulebook | No Surprises · CMS Interop · Cures · CoP | /no-surprises-act · /cms-interoperability · /cures-act · /cms-cop | 42 CFR §149 · CMS-9115-F · ONC 45 CFR §170 · 42 CFR Part 482 | ◍ Demonstrated |
| Nationwide exchange | TEFCA / QHIN Exchange | /tefca | TEFCA v1.1 · ONC HTI-1 · US Core v6 | ◍ Demonstrated |