California MTM Playbook
Your step-by-step guide to launching MTM
Medication Therapy Management turns the clinical work you already do at the counter into a billable, repeatable service. This guide covers the two things every California pharmacy asks us about: how to get credentialed and contracted, and how to fill your calendar with patients who qualify.
More of your patients qualify than ever before
CMS rewrote the MTM targeting rules effective 2025. Plans must now include all ten core chronic conditions when they identify eligible members, and the annual drug spend threshold dropped sharply. Industry analyses project eligibility roughly doubling, from around 9% to about 23% of Part D members. For a community pharmacy, that means the eligible patients are already standing at your counter.
Down from $1,623 in 2025 and over $5,000 before the rule change. A typical polypharmacy patient clears this easily.
Diabetes, hypertension and dyslipidemia alone qualify a patient on the condition test. Sound familiar?
Every enrolled patient is owed one comprehensive review a year plus quarterly targeted reviews. Recurring, scheduled clinical work.
Reimbursement varies by plan and contract. Your RxBB fee schedules show exactly what each plan pays before you book the visit.
From licensed pharmacy to paid MTM claim
Nine steps, two phases. Phase 1 gets you credentialed and contracted. Phase 2 puts patients in the chair and claims out the door. Everything below the chart explains each step in detail.
START: a licensed California pharmacy
Active Board of Pharmacy permit and at least one pharmacist ready to deliver MTM
Complete MTM certificate training
APhA program hosted by CPhA. 21 CPE hours total.
Assemble your credentialing file
Licenses, NPIs, W-9, liability insurance. One tidy folder.
Already enrolled with Medi-Cal? Skip straight to step 4.
Enroll with Medi-Cal through PAVE
DHCS online portal. One application per location.
Credential with Medi-Cal managed care plans
IEHP, Partnership, L.A. Care, Health Net, CalOptima.
Sign contracts, load fee schedules
Effective dates locked. Now you can bill.
Go live on RxBB
Eligibility, documentation and claims wired up in one place.
Build your eligible patient list
Your dispensing data plus plan criteria. Verify coverage with Ava.
Invite patients and book CMRs
Counter scripts, med sync calls, prescriber referrals.
Deliver, document, bill
Clara documents the visit. The claim goes out same day.
PAID CLAIM + a healthier patient
Then the cycle repeats: quarterly TMRs, annual CMRs, steady revenue
Quarterly targeted reviews loop back to step 8, so the calendar refills itself.
Getting credentialed and contracted
Credentialing is the paperwork mountain between you and your first MTM payment. Here is exactly what it looks like in California, and what RxBB takes off your plate. You gather the documents once. We handle the applications, follow-ups and committee cycles.
Complete an MTM certificate training program
Plans want to see that the pharmacist delivering MTM is trained on the service model. The standard path in California is APhA's Delivering Medication Therapy Management Services certificate program, hosted by the California Pharmacists Association. It teaches the full encounter: the medication therapy review, the personal medication record, the action plan, documentation and billing.
- 10 hours of self-study, completed before the live session
- One full-day live seminar via Zoom, then post-seminar patient cases within two weeks
- 21 total CPE hours and a Certificate of Achievement on completion
- Upcoming 2026 live dates: August 8 and November 14
| Early bird | Regular | |
|---|---|---|
| CPhA member | $399 | $499 |
| Non-member | $699 | $799 |
Register and see full details at cpha.com. Sign up early: the self-study takes real time and must be finished before the live day.
Assemble your credentialing file
Every application downstream pulls from the same document set. Build it once, keep it current, and Phase 1 moves fast. Here is the California checklist:
- California pharmacy permit from the Board of Pharmacy, plus your pharmacist-in-charge license
- License for every pharmacist who will deliver MTM
- NPI Type 2 for the pharmacy and NPI Type 1 for each pharmacist
- IRS W-9 and your EIN confirmation letter (CP-575)
- Professional liability insurance certificate
- DEA registration, if applicable, and a government ID for the person signing applications
- Your MTM training certificate from Step 1
Enroll with Medi-Cal through the PAVE portal
Medi-Cal enrollment is the foundation for everything else. DHCS runs it entirely online through PAVE (Provider Application and Validation for Enrollment). There are no paper applications, and an application fee applies at submission.
- Create your PAVE account and start a pharmacy application at pave.dhcs.ca.gov
- Upload the document set from Step 2, plus ownership disclosures for anyone holding 5% or more
- Submit one application per location and pay the fee
- Respond quickly to any DHCS deficiency letters; slow replies are the number one cause of delays
Already dispensing to Medi-Cal Rx members? You are likely enrolled and can skip straight to Step 4. We confirm your enrollment status for you before anything else moves.
Credential with the Medi-Cal managed care plans
Here is the part most pharmacies do not expect: Medi-Cal enrollment and plan credentialing are separate processes. Each managed care plan runs its own credentialing review before you can bill it for medical services like MTM. This is where RxBB lives every day.
- Each plan has its own application, committee calendar and re-credentialing cycle
- Applications can and should run in parallel, not one after another
- Expect verification calls and site questions; we prep you for both
Sign contracts and lock in your fee schedules
Approval letters turn into participation agreements. Read the effective date carefully: you can only bill for services delivered after it. Load every fee schedule into RxBB so the team can see, per plan, what a CMR and each TMR actually pays before booking the visit.
- Confirm MTM CPT codes 99605, 99606 and 99607 appear on each fee schedule
- Note claim submission windows and prior authorization rules per plan
- Calendar your re-credentialing dates so nothing lapses
Go live on RxBB
The moment contracts are effective, we flip on your MTM workflow: eligibility checks, encounter documentation, claim generation and denial follow-up, all in one platform your team already knows. Your first claim can go out the same week.
- Ava verifies each patient's coverage before you invite them
- Clara turns your counseling conversation into compliant documentation
- Claims go out on CMS-1500 with the right codes, modifiers and diagnoses
How long does Phase 1 take?
The RxBB difference: these tracks overlap. Start your training while we file PAVE and plan applications simultaneously. Most pharmacies are seeing their first MTM payments within one to two quarters of handing us their document file.
You gather the documents. We do the rest.
RxBB runs credentialing and contracting on your behalf: applications, deficiency responses, committee follow-ups, fee schedule loading and re-credentialing reminders. Your pharmacists stay at the counter while the paperwork moves.
Recruiting patients and communicating value
Contracts do not generate revenue. Booked visits do. The good news: your eligible patients already trust you, already visit monthly, and the service costs them nothing. Recruitment is a conversation, not a campaign.
First, know who qualifies
For Medicare Part D MTM in 2026, plans must identify members who meet all three tests below. Plans auto-enroll them, but many never get engaged. That is your opening.
The ten core chronic conditions:
Beyond Part D: Medi-Cal managed care members with complex regimens are candidates for pharmacist services billed through the medical benefit. Once you are credentialed under Part 1, RxBB routes each encounter to the right payer and benefit automatically.
Your dispensing data already knows
You do not need to buy a list. Pull candidates from the patients you fill for every month. Strong signals:
- Med sync patients with 8 or more maintenance fills
- The diabetes + hypertension + statin trio (that is 3 core conditions right there)
- Recent hospital discharge or a new specialist on the profile
- Adherence gaps, late refills or duplicate therapy flags
- Patients asking about costs, side effects or "too many pills"
Verify before you invite
Nothing kills momentum like inviting a patient whose plan will not pay. Before any outreach:
- Run the patient through Ava to confirm active coverage and the right plan
- Check the plan is one you are contracted with (your Step 5 fee schedules)
- Confirm whether the plan has already flagged the patient for MTM
- Note the best contact channel: at pickup, by phone or through a caregiver
Four ways to invite, with the words to use
The invitation matters more than the medium. Lead with the benefit to the patient, name that it is covered, and make booking effortless. Steal these scripts.
At the counter, during pickup
Attach the invite to a visit they are already making. Offer two specific time slots, not an open-ended "sometime."
On the phone, during the sync call
Your med sync list is pre-filtered for polypharmacy. Work through it ten calls at a time.
Bag inserts and shelf cards
Print in RxBB blue, keep it to two sentences, and put one in every polypharmacy patient's bag for a month.
Local prescribers and clinics
One fax-able one-pager to the five clinics that write most of your scripts. Prescriber referrals arrive pre-sold.
How to communicate the value
Patients say yes when they hear what is in it for them. These five points, in this order, do the work:
It costs you nothing
This is a covered benefit your plan already pays for. No copay, no bill, nothing to buy.
Real time with your pharmacist
A private 20 to 30 minute sit-down, not a rushed chat over the counter.
You leave with a plan
A complete medication list and a written action plan you can hand to every doctor you see.
We catch problems early
Duplicate therapies, interactions and side effects get found here, not in the ER.
It often saves money
Lower-cost alternatives and deprescribing opportunities come up in most reviews.
Your whole picture, in one place
Prescriptions, OTCs, vitamins and herbals reviewed together, which no single prescriber sees.
When patients hesitate
| They say | You say |
|---|---|
| "My doctor already checks my medications." | "Your doctor sees what they prescribe. We see everything you actually fill, plus your over-the-counter and herbal products, all in one review. We work with your doctor, not around them." |
| "I don't have time." | "It is 20 to 30 minutes, once a year. We can do it while your refill is being filled, or by phone if that is easier." |
| "Is this a sales pitch?" | "No. There is nothing to buy. Your plan asks us to do this because it keeps you healthier and out of the hospital." |
| "Will my plan charge me later?" | "No copay and no bill. It is a benefit you already pay for through your plan. You might as well use it." |
Then make it a rhythm, not a one-off
MTM is designed as a recurring service. Once a patient is in, the calendar refills itself, and so does the revenue line.
Comprehensive Medication Review
The full interactive sit-down, with a written summary, medication list and action plan in the CMS standardized format.
Once a yearTargeted Medication Reviews
Shorter, focused check-ins on specific issues: a new drug, an adherence gap, a therapy change after discharge.
Every quarterDocument and bill every touch
Each CMR and TMR is a billable encounter. Clara documents it, RxBB codes it and the claim goes out the same day.
Every visitHow RxBB powers your MTM program
Four AI agents cover the billing lifecycle so your pharmacists do the clinical work and none of the administrative work.
Ava
Confirms coverage and the right plan before you invite a patient, so every booked visit is a payable visit.
Clara
Listens to the encounter and produces compliant documentation, the medication record and the action plan.
Jasmine
Scores every MTM claim before it leaves, catching coding and eligibility issues while they are still fixable.
Elena
Reads every denial, finds the root cause and drives the correction, so revenue does not leak quietly.
Ready to launch MTM at your pharmacy?
Already on RxBB? Message your account team or email support@rxbb.io with "MTM" in the subject line and we will open your credentialing file this week. New to RxBB? Let us show you the whole workflow, from eligibility to paid claim.