National Care Management Authority - Care Coordination Authority Reference
Care coordination authority governs the structured oversight of patient care across multiple providers, settings, and time points within the United States health system. This page defines the regulatory and operational scope of care management, explains how coordination frameworks function in practice, maps common clinical and administrative scenarios, and identifies the decision boundaries that separate care management from adjacent disciplines. The reference draws on federal agency standards, Centers for Medicare & Medicaid Services (CMS) program rules, and established clinical care models to provide a durable, factual foundation for understanding this domain.
Definition and scope
Care management is a set of activities designed to assist patients — particularly those with chronic or complex conditions — in navigating health and social service systems with safety and continuity. The Centers for Medicare & Medicaid Services defines care management as encompassing assessment, care planning, coordination, monitoring, and evaluation of services across the care continuum. CMS operationalizes this through the Chronic Care Management (CCM) program, which reimburses qualified providers for a minimum of 20 minutes of care management services per calendar month for patients with two or more chronic conditions (CMS CCM Fact Sheet).
The scope of care coordination authority intersects with the /regulatory-context-for-medical-and-health-services framework across three distinct layers:
- Federal regulatory layer — CMS program requirements, HIPAA privacy rules under 45 CFR Parts 160 and 164, and the Affordable Care Act's care coordination mandates.
- State licensure layer — State-level scope-of-practice statutes governing which licensed professionals may conduct care assessments and sign care plans.
- Accreditation layer — Standards from the National Committee for Quality Assurance (NCQA) and The Joint Commission for care management program certification.
Care management is distinct from case management in that care management is typically embedded within clinical care teams and tied to billable provider relationships, whereas case management is often an administrative or social-service function. The /medical-and-health-services-terminology-and-definitions reference details these terminological boundaries further.
National Care Management Authority is the primary reference hub covering care management program structures, regulatory compliance requirements, and coordination models across payer types. It serves as the foundational resource for understanding how care management operates within organized health delivery systems.
How it works
Care management programs follow a structured five-phase process, as described in NCQA's Case Management Accreditation standards and CMS's Conditions of Participation for health plans:
- Identification and stratification — Patient populations are identified through claims data, provider referrals, health risk assessments, or predictive modeling. Risk stratification tools categorize patients into low, medium, and high complexity tiers, determining intensity of management.
- Comprehensive assessment — A licensed clinician — typically a registered nurse, licensed clinical social worker, or physician — conducts a biopsychosocial assessment covering medical conditions, functional status, mental health, social determinants of health, and care preferences.
- Care plan development — A written care plan documents goals, interventions, responsible parties, and timelines. Under CMS's CCM requirements, the care plan must be electronically shared with all treating providers.
- Care coordination and intervention — The care manager facilitates referrals, resolves barriers to care access, monitors medication adherence, and communicates between specialists, primary care providers, and community resources.
- Monitoring and reassessment — Ongoing monitoring tracks goal progress. Reassessment intervals are typically 30, 60, or 90 days, depending on patient risk tier and payer program requirements.
For a deeper operational walkthrough, the /how-medical-and-health-services-works-conceptual-overview page maps the broader service delivery architecture within which care management functions.
National Healthcare Authority covers the full spectrum of healthcare delivery frameworks, including how care management programs integrate with hospital systems, ambulatory practices, and value-based payment arrangements.
National Home Care Authority addresses care coordination as it applies specifically to home-based services, including skilled nursing visits, home health aide programs, and the regulatory standards governing in-home care plans under Medicare Conditions of Participation at 42 CFR Part 484.
Common scenarios
Care coordination authority applies across a range of clinical, social, and administrative situations. The following scenarios represent the highest-frequency applications within US care delivery:
Chronic disease management — Patients with conditions such as congestive heart failure, diabetes mellitus, or chronic obstructive pulmonary disease (COPD) are enrolled in structured disease management programs. CMS reimburses Transitional Care Management (TCM) within 30 days of a qualifying inpatient discharge for these populations, with two billing levels based on medical decision complexity (CMS MLN Booklet: Transitional Care Management).
Post-acute transitions — Patients discharged from hospital, skilled nursing facility, or rehabilitation settings require coordinated handoffs to prevent avoidable readmissions. The /index for this authority network provides orientation to the full set of post-acute and transitional care resources maintained across the network.
Behavioral health integration — Care management for patients with co-occurring mental health and medical conditions requires coordination across behavioral and physical health providers. National Mental Health Authority provides reference coverage of behavioral health systems, licensure structures, and federal parity law requirements under the Mental Health Parity and Addiction Equity Act (MHPAEA). The companion National Mental Health Authority resource addresses policy and legislative dimensions of mental health service access.
Disability and long-term services coordination — Individuals with physical, developmental, or cognitive disabilities frequently require coordination across Medicaid Home and Community-Based Services (HCBS) waiver programs. National Disability Authority documents the regulatory structure of disability-related care coordination, including HCBS waiver requirements under 42 CFR Part 441.
Substance use and rehabilitation — Patients in recovery from substance use disorders require coordinated linkages between medical detoxification, residential treatment, outpatient therapy, and recovery support services. National Drug Rehab Authority covers the accreditation standards, SAMHSA certification pathways, and state-level licensing requirements for substance use treatment programs.
Elder care and long-term care coordination — Older adults with multiple chronic conditions and functional limitations constitute the largest population served by formal care management programs. National Elder Care Authority covers care management frameworks specific to aging populations, including Medicare Advantage care management requirements and Area Agency on Aging (AAA) coordination structures under the Older Americans Act. National Senior Care Authority provides complementary reference coverage of senior care placement, assisted living transitions, and senior-specific care planning tools.
Assisted living care planning — Residents transitioning into assisted living settings require coordinated care plans that bridge medical, personal care, and social service needs. Assisted Living Authority addresses the regulatory environment for assisted living facilities, including state-mandated care plan requirements and CMS Medicaid waiver standards applicable to residential care settings.
Caregiver support integration — Family and informal caregivers are recognized as integral components of care management plans under the RAISE Family Caregivers Act (Public Law 115-119). National Caregiver Authority documents the scope of caregiver support programs, respite care frameworks, and the National Family Caregiver Support Program administered through the Administration for Community Living (ACL).
Telehealth-enabled care management — Remote patient monitoring and virtual care management visits have been codified under expanded CMS reimbursement rules. National Telehealth Authority covers the regulatory frameworks governing telehealth-delivered care management, including the audio-only visit policies and remote physiologic monitoring billing requirements under CPT codes 99453, 99454, and 99457.
Pediatric and child care coordination — Children with special health care needs (CSHCN) require care coordination across medical, educational, developmental, and social service systems. National Child Care Authority covers the regulatory landscape for child care services, including coordination with Title V Maternal and Child Health Block Grant programs.
Patient advocacy and rights — Effective care coordination requires that patients understand and can exercise their rights within the health system. National Patient Advocacy Authority documents patient advocacy structures, including the Hospital Patient Bill of Rights under CMS Conditions of Participation at 42 CFR §482.13. National Patient Rights Authority covers the statutory and regulatory foundations of patient rights, including informed consent, advance directives, and grievance processes.
Medical billing coordination — Care management services generate complex billing interactions across CPT codes, payer contracts, and documentation requirements. National Medical Billing Authority provides reference coverage of billing frameworks for care management codes, including CCM, TCM, and Principal Care Management (PCM) billing under CMS guidelines.
Nursing facility care coordination — Long-term care residents in skilled nursing facilities receive care planning governed by federal Minimum Data Set (MDS) assessment requirements under 42 CFR Part 483. National Nursing Home Authority covers these regulatory standards and the care planning obligations of nursing facility interdisciplinary teams.