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Remote Care Services

Monitoring and care coordination between visits, so problems get caught before they become admissions.

Request this service(513) 393-5166
A clinician wrapping a blood pressure cuff around a patient's upper arm.

Chronic conditions are managed in the 8,760 hours a year a patient is not in a clinic. Our remote programs put clinical eyes on those hours.

We go beyond providing exceptional care to patients. Our team supports clinics and practices directly, so your patients receive the attention and assistance they need between appointments.

What's included

Inside remote care services

Each service below is delivered against the plan on file and documented so your care team can rely on it.

  • A nurse at a computer working through a patient's records.

    Chronic Care Management (CCM)

    A Medicare Part B program for patients managing two or more chronic conditions, with a minimum of 20 clinical staff minutes per month.

    CCM covers monthly clinical reviews, telephone check-ins, physician consultations, referrals, prescription management, chart reviews and help scheduling appointments. Research indicates participation can reduce hospital admissions and long-term healthcare costs. Common qualifying conditions include Alzheimer's disease and related dementia, cardiovascular disease, COPD, depression, diabetes, hypertension and infectious diseases such as HIV/AIDS. Enrolment happens during an in-person evaluation or Annual Wellness Visit, with written or verbal consent recorded. CPT codes: 99490, 99491, 99439 and more.

  • An older person using a blood pressure monitor at their own table at home.

    Remote Patient Monitoring (RPM)

    Connected devices stream vitals to our clinical team so trends are caught early.

  • A clinician checking a continuous glucose sensor worn on a patient's upper arm.

    Continuous Glucose Monitoring (CGM)

    Continuous glucose data and coaching for patients managing diabetes.

  • A clinician talking through a care plan with a patient across a desk.

    Principal Care Management (PCM)

    Focused management for patients with a single high-risk chronic condition.

Who this is for

Is this the right service for you?

  • Patients with two or more chronic conditions
  • Physician groups and clinics wanting a care-coordination partner
  • Managed Care Plans seeking better member outcomes
  • Practices billing CCM, PCM, RPM and BHI who need reliable clinical time
Ask about eligibility

Funding & eligibility

Billing providers may include physicians, physician assistants, nurse practitioners, certified nurse midwives, clinical nurse specialists and pharmacists. Medicare Part B covers 80% with a patient co-pay, and patients may opt out at any time.

Available across Ohio

We deliver this service in all 8 counties we cover.

Other programs

People often need more than one kind of support

Peniel delivers all of it under one provider, one plan and one point of contact.