AI APCM
Introduced in 2025 by CMS Advanced Primary Care Management improves patient outcomes and delivers up to $280,000 in extra revenue per year for every 1,000 patients to practices. But APCM pays monthly only if all thirteen service elements are delivered and documented for every enrolled patient. The challenge is effort and throughput. Our AI Agent handles both.
- EligibilityEligible
- Tiering
- EnrollmentEnrolled
- Care Plan
- Monthly Execution
- Referral ClosurePending
- Documentation / AttestationPending
Panel
- Eligible
- Eligible
- Eligible
- Not eligible
Tiering
- Medicare
- Conditions
- QMB
- Level
- Assigned
Voice outreach On call
Consent
- Consent
- Captured
- Documented
Initiating visit
AWV plan
- Care plan
Tasks Scheduled
- Screening
- Labs
- Referral
- Follow-up
Open tasks Continuous
- ScreeningScheduled
- LabsCompleted
- ReferralOutreach
- Follow-upQueued
This month
Referral
- Routed
- eRAF cleared
- Consult completed
- Report returned
Care plan
- ReferralClosed
Care plan Active
CurrentMonthly evidence
- Elements
- Care plan
- Claim
Attestation
AttestedMonthly Attestation
13/13
Elements documented
- Active care plan current
- Claim evidence generated
How AI APCM works
One continuous workflow from eligibility to monthly attestation.
-
Who qualifies, and at what level
- Reads the panel and flags Medicare eligibility.
- Counts chronic conditions and checks QMB status.
- Assigns the correct APCM level automatically.
-
Consent, then the initiating visit
- Voice-first outreach explains the program to the patient.
- Enrolls the patient.
- Captures consent and documents it.
- Books the initiating visit.
-
From document to trackable work
- Breaks the Annual Wellness Visit plan into individual actions.
- Screenings, labs, referrals, and follow-ups become scheduled tasks.
- Nothing sits static in the chart as a PDF.
-
What makes the fee earnable
- Runs outreach against every open task, continuously.
- Keeps the care plan moving instead of theoretical.
-
From routed to resolved
- Routes referrals and clears the eRAF.
- Tracks through to completed consult and returned report.
- Feeds closure back into the care plan.
-
The evidence CMS requires
- Maintains the active care plan CMS requires.
- Produces the monthly evidence behind every claim.
Expected outcomes
- 13/13
- Service elements delivered monthly
- Continuous
- Outreach against the care plan
- Audit-ready
- Evidence behind every claim
An active care plan, worked every month — not a document sitting in the chart.
- Eligibility & Tiering
- Consent & Enrollment
- Care Plan Tasks
- Monthly Attestation
See the AI workforce in action
Tell us about your organization and we'll walk you through a personalized assessment.
Request an AssessmentCompleted Actions
- Closed care gaps
- Scheduled visits
- Completed referrals
- Updated documentation
Throughput