Run multiple virtual care programs. No broadband required for your patients.
CareAtlas runs RPM, CCM, TCM, and APCM end-to-end for FQHCs and RHCs — APCM-ready from day one. Cellular-connected devices let your dual-eligible and rural patients participate without a smartphone or an internet connection. Full support for the current standard CPT codes, and G0511 where it applies.
The operating reality inside community health centers in 2026
Grant pressure, dual-eligible complexity, workforce shortages, broadband gaps. CareAtlas is built for the specific version of these challenges FQHC and RHC leaders are living.
G0511 covers the work. Capturing the elements is the hard part.
FQHCs and RHCs bill care management under G0511 — but a clean claim depends on capturing every qualifying touch, minute, and care-plan element. CareAtlas captures all of it as the work happens.
Your highest-need patients carry the heaviest coordination load — and that's exactly what APCM is built to fund.
QMB and dual-eligible patients carry the highest coordination burden and the deepest unmet needs. APCM's Level 3 tier ($117 per patient per month) exists to fund exactly that. CareAtlas runs the coordination infrastructure so these patients get the care they need.
You can't hire the navigators the program needs in your labor market.
Nursing and care-coordination talent is scarce nationally and sparser in the rural and underserved communities FQHCs and RHCs operate in. Outsourcing the care-management capacity to a licensed national team solves the staffing constraint without compromising clinical quality — and without diverting your clinical workforce from the in-clinic work.
The technology can't fail on the patient side.
Many FQHC and RHC patients don't have home broadband, don't own a smartphone, and wouldn't open an app if they did. CareAtlas's RPM devices are cellular-connected and pre-provisioned — no WiFi, no smartphone, no app. Our navigators call the patient. The patient doesn't log in to anything.
We have a model that fits.
Every organization is different. CareAtlas offers three models so you get exactly the level of support you need — from full-service to platform-only.
CareAtlas Complete
Full-service care coordination. We provide the navigators, technology, devices, enrollment, billing, and care delivery — end to end. For hospitals, CareAtlas serves as provider of record — no upfront investment required. For practices and community health centers, revenue consistently exceeds program costs.
CareAtlas Extend
Already have some care coordination staff? We augment your team with the HealthQuilt platform, device logistics, and overflow navigator support — filling gaps without replacing what works.
CareAtlas Connect
Platform-only access to HealthQuilt — our AI-assisted care coordination software, EHR integration, analytics, and compliance tools. You bring the team. We bring the technology.
Four programs.
One operating partner.
Each of these programs runs inside HealthQuilt and delivers both clinical impact and Medicare revenue. Together they form an integrated care-management program for your Medicare population.
Remote Patient Monitoring
RPM: Daily visibility into patient health
Cellular-connected devices ship directly to patients — blood pressure cuffs, glucose monitors, pulse oximeters, scales. No WiFi. No smartphone. No patient app. Daily readings are monitored by dedicated care navigators with AI-assisted alerts that catch deterioration before it becomes an ER visit.
Chronic Care Management
CCM: Consistent care between appointments
Monthly navigator check-ins, personalized care plans, medication management, and social determinant screening — all documented and billed under 99490/99491. Only about 18% of eligible Medicare discharges receive a TCM bill, even though roughly 52% of unbilled eligible discharges already had a qualifying visit within 14 days. CareAtlas helps close that gap.
Transitional Care Management
TCM: The critical 30 days after discharge
Navigator outreach within 48 hours of discharge. Medication reconciliation. Follow-up scheduling. 30 days of transition support during the window when patients are most vulnerable — and when the vast majority of billable TCM episodes go uncaptured. Only ~9% of eligible Medicare discharges result in a TCM bill, and among those unbilled, over half already had a qualifying office visit within 14 days — revenue left on the table.
Advanced Primary Care Management
APCM: The newest Medicare revenue pathway
APCM reimburses across three risk-stratified tiers — $16/mo (Level 1), $54/mo (Level 2), and $117/mo (Level 3) — with no time-tracking requirements. For a panel of 200 patients at Level 2, that's ~$129K/year in recurring revenue, billable alongside RPM.
