Care Coordination Requirements Under the CMS ACCESS Model

Learn how care coordination works under CMS ACCESS, including required care updates, secure delivery methods, and documentation expectations for applicants.

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Why care updates are a reportable workflow

Under the CMS ACCESS Model, care coordination is not informal communication. It is a documented, structured process.

Applicants must show how they support electronic updates to primary care providers and referring clinicians.

What CMS expects for care coordination

Organizations must demonstrate:

  • Ability to identify the patient’s PCP or referring clinician

  • Electronic care updates at key milestones


    • Care initiation

    • Clinical milestones

    • Completion

  • Use of HIPAA-compliant secure delivery methods

  • Retention of evidence showing delivery or reasonable delivery attempts

Care updates must be part of the operational model.

Why care coordination is a technology requirement

ACCESS requires care updates to be:

  • Standardized

  • Electronically transmitted

  • Traceable

That means care coordination depends on templates, delivery channels, and audit logs, not just clinician communication.

What applicants should be able to describe

Applications should clearly outline:

  • When updates are triggered

  • How update content is standardized

  • How delivery occurs

  • How delivery evidence is stored

This demonstrates that coordination is reliable and repeatable.

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Mark Boudreau
Co-founder Mark Boudreau is the COO of Healthfully and brings more than 30 years of success across the technology, product and service, and healthcare industries. Mark previously served as a partner at Accenture and Vice President of Strategy at Orion Health.