Talk with us CARE PROGRAM GUIDE · MTM
Medication Therapy Management
A medication expert reviews a patient’s medicines, helps the patient understand them, and sends important questions back to the prescriber.
FIRST, THE SHORT ANSWER
What would MTM add to care?
Medicare Part D MTM is established by a Part D plan sponsor for targeted beneficiaries. It is not a general Original Medicare Part B care-management claim and should not be confused with RTM or CCM.
No RTM device is required. Use secure medication reconciliation, documentation, and communication tools required by the plan and the participating providers.
PATIENT & PRACTICE FIT
Could this help people you treat?
Potential fit
A Part D sponsor has identified the beneficiary under its approved MTM criteria, and a contracted pharmacist or other qualified provider can deliver the required service.
Check before enrolling
No plan MTM eligibility or contract; treating a routine dispensing conversation as an MTM encounter; or quoting a Part B fee-schedule rate for Part D MTM.
PATIENT EXPERIENCE
A structured review of all medications, discussion of goals and barriers, a take-home medication list and action plan, and communication with prescribers when changes are needed.
SEE IT IN PRACTICE
From medication questions to an action plan.
Meet Luis: his Part D plan selects him for MTM, and a contracted pharmacy arranges a medication review.
The goal: Give Luis a clear medication list and an action plan for medicine-related questions.
Choose a stage to see what the patient, treating practice, and PrimeVital’s agreed team each do.
Verify selection
Before the review- Patient / caregiver
- Receives a plan-based invitation and chooses whether to participate.
- Treating practice
- Confirms sponsor eligibility and the provider’s contract.
- PrimeVital’s agreed role
- Can help organize agreed outreach and administrative routing.
- What gets recorded
- Sponsor selection, provider arrangement, service protocol, and payment terms.
Illustrative scenario, not a patient record or clinical protocol. Clinical targets, review frequency, staff qualifications, escalation, and service hours are agreed with the treating practice. Clinical decisions stay with qualified personnel.
SAMPLE CARE PLAN
A plan the patient and the team can understand.
Give Luis a clear medication list and an action plan for medicine-related questions.
- Patient task
- Bring prescription, nonprescription, and supplement information and discuss how he uses them.
- Clinical owner
- The qualified medication-review provider identifies issues; prescribers decide treatment changes.
- Team follow-up
- Prepare the review, medication list, action plan, and documented prescriber handoffs.
- Review
- Follow identified issues and the sponsor’s targeted-review schedule.
Continuing follow-up
Use the sponsor’s comprehensive and targeted-review requirements. MTM is not automatically a monthly subscription, and dispensing alone is not a completed review.
YOUR INVOLVEMENT
Clinical ownership stays with the treating practice.
The agreement names the people, work, coverage hours, records access, and handoffs. Technology and operational support do not transfer clinical or billing authority.
What your clinician does
The Part D plan sponsor establishes the program and payment arrangement. The service provider’s role and remuneration come from the sponsor or an authorized contractor—not an assumed Part B professional claim.
What supporting staff can do
Licensed pharmacists and other qualified providers may furnish MTM according to plan requirements. A physician practice may coordinate recommendations, but that does not transform MTM into RTM.
What we can organize with you
PrimeVital can explore medication-workflow coordination and partner handoffs where a plan or clinical organization has a defined arrangement; we do not represent Part D MTM as an established PrimeVital billing product.
PrimeVital’s full care arrangement includes applicable devices and a care-management team. The program determines which resources and professional qualifications are needed. Interactly can support front-desk tasks within the agreed scope; 24/7 PrimeVital clinical coverage is not assumed.
REQUIREMENTS BEFORE LAUNCH
Make the pathway ready before enrolling patients.
- Confirm the specific Part D sponsor selected the beneficiary for MTM.
- Verify the pharmacy or provider contract, service protocol, documentation, and payment.
- Complete required medication review, patient action plan, and prescriber handoff.
- Do not present MTM as an independent Original Medicare Part B claim.
Detailed operating workflow and technology
- 1
Confirm
Verify Part D plan membership, MTM targeting, referral, and contracted provider pathway.
- 2
Review
Gather the complete medication regimen and perform the required comprehensive review.
- 3
Act
Identify problems, give the patient an action plan, and route recommendations to prescribers.
- 4
Document
Meet sponsor reporting, follow-up, quality, and payment requirements.
Technology and records: No RTM device is required. Use secure medication reconciliation, documentation, and communication tools required by the plan and the participating providers.
GETTING PAID
Who receives payment, and what earns it?
Care need, completed services, evidence, and the actual payer determine the claim. A covered service or an enrollment is not the same as collected revenue.
The Part D sponsor or its authorized contractor pays according to the provider arrangement. There is no universal Part B MTM fee to multiply by pharmacy patients. PrimeVital’s participation would be separately scoped and contracted.
Original Medicare Part B is not the standard payer for Part D MTM. CMS requires Part D sponsors to maintain an MTM program for targeted beneficiaries.
Medicare Advantage prescription-drug plans and standalone Part D plans may administer MTM differently; commercial medication-management contracts also vary. Verify the sponsor and agreement.
Do not infer a Part B coinsurance amount. Check the beneficiary’s Part D plan MTM benefit and any separate services before discussing cost.
Payment boundaryMTM, RTM, and CCM can all involve medication-related conversations but have different clinical purposes, owners, technologies, and payment pathways. Do not relabel the same activity to claim multiple services.
2026 code reference and an illustrative service check
The sponsor or contractor’s agreement establishes eligible reviews, deliverables, submission rules, and payment. A Part B fee-schedule amount is not the price of a Part D medication review.
These are code-family summaries, not complete descriptors or payment estimates. Check the current code set, payer, clinician, setting, date, unit edits, and required add-on base code.
| Code / pathway | What it describes | Before billing |
|---|---|---|
| Part D MTM | Sponsor-defined program | Eligibility, delivery, documentation, and payment depend on the sponsor’s approved program and contract. |
| 99605–99607 | Medication therapy management CPT family | These codes are not a general Original Medicare Part B Physician Fee Schedule payment route. |
Questions before a claim
Can an independent pharmacy participate?
Yes, if it meets the sponsor’s provider and contracting requirements. An independent pharmacy should start with the plan or its MTM contractor.
Is MTM the same as RTM?
No. MTM is plan-sponsored medication review; RTM is a separate Part B therapeutic monitoring pathway with qualifying technology and practitioner rules.
FINANCIAL PICTURE
See how participation, collections, and costs change the result.
Start with one supported pathway. Do not multiply every patient by every possible code. Use verified payer terms and the written PrimeVital scope before making a business decision.
Calculate by your actual contract’s service units
Start with accepted comprehensive reviews and targeted services, their agreed fees, and actual remittances. Subtract pharmacist time, outreach, documentation, platform charges, and agreed support fees. Annual comprehensive reviews and quarterly targeted reviews do not establish monthly per-patient pharmacy income.
BENEFITS TO MEASURE
Define success before the first patient starts.
Agree on a baseline and review period. These are measures to track, not promised results or guaranteed payment.
Medication clarity
Patient understanding and current medication lists.
Issue resolution
Identified medication problems addressed with prescribers.
Completion
Completed reviews and follow-up required by the sponsor.
PRIMARY SOURCES
Check the rule before a real claim.
Reviewed October 7, 2026 against current CMS guidance. These guides describe 2026 pathways; proposals for later years are not effective requirements. Coverage, contracts, scope, and patient facts can change the answer.
APPLY THIS TO YOUR PRACTICE
Start with a patient group and a clear question.
Tell us your practice type, payer mix, and workflow. We can map clinical fit, your involvement, available support, launch requirements, and financial assumptions to verify.
DESIGN A PRACTICAL STARTING POINT
Tell us where the workflow is breaking. We’ll show you where to begin.
Send us a message
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