What Primary Care Needs to Know
ACCESS is designed to complement, not replace, a patient's existing primary care relationship. A primary care provider can refer a patient to a participating ACCESS organization for supplemental technology-supported chronic care while continuing to see that patient as usual.
Referral Workflow
CMS describes the workflow as: the primary care provider (or a referring clinician) refers an eligible patient to a participating ACCESS organization; that organization delivers the technology-supported care described in our ACCESS Model overview; the primary care provider then receives structured updates and can bill the co-management payment for reviewing them and coordinating on the patient's behalf.
Data Sharing
ACCESS organizations must share care updates through HIPAA-compliant secure electronic methods — Direct Secure Messaging, a network-supported push mechanism, or HIPAA-compliant eFax. By July 2027, all participants must connect to a CMS Aligned Network or Health Information Exchange, so a primary care practice can query structured patient data (biomarkers, patient-reported outcome measures, medications) through its own existing systems.
Care Coordination
The primary care provider's coordination role is what the co-management payment compensates: reviewing a documented ACCESS care update and performing at least one related activity, such as a medication adjustment, problem-list update, or referral.
Patient Updates
CMS describes three key points at which a primary care provider receives a structured update: at care initiation (care plan and baseline measures), at care escalation (if clinical needs change or care is transitioned), and at care completion (a summary at the end of the care period).
Technology Integration
No special ACCESS enrollment or new technology purchase is required for a primary care practice to receive updates — CMS describes delivery "through your existing workflows" via the secure electronic methods above.
Outcomes
The participating ACCESS organization, not the primary care practice, is accountable for the outcome targets tied to its own payment. The primary care provider's role is coordination and continuity, reflected in the separate co-management payment.
Documentation
To bill the co-management payment, document your review of the ACCESS care update and the specific coordination activity performed (e.g., the medication change or problem-list update) — CMS's description ties the payment to that documented review and action, not simply to having received an update.
Collaboration
A patient can continue seeing their primary care provider and any other Medicare provider as usual — CMS is explicit that ACCESS organizations provide supplemental chronic care support rather than replacing the primary care relationship.