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Transitional Care Management (TCM) Services

Transitional Care Management (TCM) is a term for services that healthcare personnel provide to patients following discharge from an inpatient hospital visit for a period of 29 days.  These services are intended to reduce the need for a readmission to the hospital for the same condition or problem.

TCM services are provided within a specific timeframe:

  • Patients are contacted within two business days following hospital discharge. This is usually a phone call to identify any needs for additional resources or provide support to a caretaker.
  • A face-to-face visit with a healthcare provider should take place within 7-14 business days following the hospital discharge, depending on the nature of the hospitalization.

TCM services must be billed according to specific insurance guidelines:

  • Billing for TCM services is similar to billing for routine services received from a healthcare provider during an office visit.

For example, on the date of a face-to-face visit with a healthcare provider any necessary copayment, coinsurance or deductible that normally applies for outpatient medical services is paid (such as office visits), as per your insurance health plan.

A healthcare provider will submit a claim for the visit to an insurance company. When submitting a claim to an insurance payer for this service, the reported date for this service will be the 30th day following hospital discharge. Any payment made at the time of the face-to- face visit will be applied to the patient account and will be linked to an encounter date 29 days after the hospital discharge vs. the actual date of the face-to-face visit with the provider. This can sometimes be confusing when an explanation of benefits (EOB) is received from an insurance carrier or itemized statements from the healthcare provider. The date for the face-to-face visit will be reported as the 30th day following the hospital discharge date; this is not an error but rather a requirement by the insurance carriers in order for the claim to be paid accurately.

If a patient is readmitted to the hospital within the 30-day period following the first hospital discharge, the service received face-to-face will be billed as a regular outpatient (office-based) service instead of as TCM services.

If you have any additional questions about TCM services, how they differ from regular follow-up visits, or how your insurance carrier will be billed for TCM services do not hesitate to speak with your healthcare provider staff who can help you better understand this process.