Medicare now pays for the part medicine doesn't cover.
Navigate Care is the end-to-end software for physician practices and nurse practitioners to deliver Medicare's Principal Illness Navigation (PIN) program — from referral and eligibility, through navigator-led care plans and built-in patient calling, to CMS-compliant time tracking and billing of HCPCS G0023 and G0024.
One platform for the entire PIN workflow — from referral to billable G0023 / G0024.
~0M
Medicare beneficiaries
(CMS, 2024)
0
PIN program live
(CMS Final Rule)
~$0
Per patient / month
G0023 + 1×G0024 (illustrative)
0%
Time-tracked
audit-ready by month
The other half of healthcare finally has a code.
For seriously ill Medicare patients, outcomes are decided outside the exam room — by transportation, food, caregiver capacity, and access to community programs. In 2024, CMS finally created a way for physician practices to get paid for that work: Principal Illness Navigation.
Food & transport gaps fuel readmissions
A cancer patient who can't get to chemo. A heart-failure patient with no groceries. The clinic can't fix it from the exam room — and Medicare wasn't paying anyone to try.
Caregivers burn out alone
Roughly 53 million Americans are unpaid family caregivers (AARP, 2020). When the caregiver collapses, the patient ends up in the ER — and back on your census the same week.
Behavioral health & SDOH never reach the chart
Depression, isolation, housing insecurity, language barriers — the things that actually drive outcomes — get logged in your team's heads, not in a billable workflow.
Step 1 — Referral & Consent
The patient enters your portal — consent included.
Your front desk (or a referring physician, or an internal AWV) adds a PIN-suspect patient straight into Navigate Care. In the same screen they capture demographics, the Medicare ID, and the primary diagnosis — no spreadsheet, no fax, no double entry into the EHR.
Then the eligibility E/M visit is scheduled with the billing practitioner, and the CMS-required PIN consent — including the cost-sharing disclosure — is read aloud and captured (verbal-attested or e-signed). Every word is timestamped, witnessed, and saved to the audit trail. The patient lands in the navigator queue, ready for Step 2.
Step 2 — Eligibility E/M + AI Care Plan
One face-to-face visit unlocks an entire year of PIN.
The billing physician or NP sees the patient on a video visit (audio fallback for patients who can't do video). It's a normal E/M — and it's billable on its own (e.g. CPT 99213/99214). What's different: Navigate Care is listening.
As the patient describes their life — transportation, food, caregiver, behavioral health — our AI pulls those barriers out of the conversation in real time. The physician confirms PIN eligibility with one click. Navigate Care then drafts the patient-led care plan from that very conversation: the services to deliver, the goals, and the 9 CMS-required PIN service elements, all pre-filled for the navigator to refine. One visit produces two billable artifacts — the E/M today, and the entire next year of PIN navigation, billed in calendar-month increments.
Step 3 — Navigator Calls + Auto-Generated Tasks
The navigator calls the patient — from inside the platform.
Sarah, the navigator, opens Margaret's chart and dials right inside Navigate Care — no second softphone, no pasting numbers. The caregiver is conferenced in. The call is recorded, transcribed live, and HIPAA-aligned end-to-end.
Sarah walks the patient through the care plan and captures preferences: medication reminder daily at noon, chemo ride Tuesday at 8 AM, a Meals on Wheels box on Mondays. As the call ends, Navigate Care turns those preferences into scheduled tasks on the navigator's queue — automated outreach, manual follow-ups, and time-bound reminders. The full call duration is logged against Margaret's calendar-month PIN minute counter, so every minute now counts toward G0023.
Step 4 — Time Tracking + CMS Billing
Cross 60 minutes in the calendar month? You just billed G0023.
As the navigator works — calls, family meetings, social-services coordination, Playbook lookups — Navigate Care times every PIN-qualifying activity and aggregates it per patient, per calendar month. The counter ticks live; the navigator and the billing manager can both see exactly how close each patient is to the next billable threshold.
When a patient crosses 60 minutes, G0023 unlocks automatically. Each additional 30 minutes unlocks an add-on G0024. Navigate Care produces a defensible audit packet — supervising practitioner, navigator, every activity, every timestamp — and a practice-level rollup of net-new Medicare revenue, ready to drop into your existing billing system. Nothing missed; nothing double-counted.
Step 5 — The Playbook
Every federal, state, and county program — one search box.
The Playbook is the thing your team has been building in spreadsheets and group texts for years — only it's already built. It's a curated, searchable directory of federal, state, county, and local programs that address Health-Related Social Needs: food, transportation, housing, energy, caregiver respite, behavioral health, language assistance.
The navigator types a need ("El Paso, TX — food assistance") and Navigate Care returns ranked, ZIP-aware results with eligibility, contact, hours, and how to refer the patient. One click sends the referral, hands the patient the program contact, logs the action against the patient's PIN month, and creates a 7-day follow-up to confirm enrollment. No PDF hunting. No broken phone numbers. No more uncompensated work.
The PIN revenue math
~$153K / year per 100 PIN patients.
Without hiring more clinicians.
100 patients × ~$128/mo (G0023 + 1×G0024 at CY2024 PFS, non-facility) × 12 months. Illustrative; actual reimbursement varies by locality and payer mix.
Built for the practices that live with serious illness.
Primary Care & Internal Medicine
Oncology, HIV, & Specialty Clinics
Nurse-Practitioner & FQHC Practices
Why Navigate Care wins with practices.
"A new Medicare line of business that pays for the work our navigators were already doing for free."
What practices tell us
Recurring theme from PIN readiness reviews
~$1.5K
Per PIN patient per year (CY2024 PFS, illustrative G0023 + 1×G0024 monthly).
Fewer ED visits and admissions when food, transport, and caregiver gaps are closed early — the unit economics of PIN.
"One platform. One time log. One claim packet. PIN works the way our practice already runs."
Operational design principle
How Navigate Care fits the physician-office workflow
Built for the way Medicare actually audits PIN.
Consent. Calendar-month minute thresholds. Supervising practitioner. The 9 service elements. Navigate Care builds the audit trail as your team works — not after the fact.
HIPAA + BAA
A Business Associate Agreement is executed before production PHI ever touches the system. Encryption in transit and at rest by default.
Role-based access
Physician, navigator, biller, and admin each see only what they need. Granular permissions follow the patient, not the user.
CMS audit-ready
Time-stamped activity log per patient per calendar month. Consent capture, supervising practitioner, and the 9 PIN service elements documented in one packet.
No rip-and-replace
Sits alongside Epic, Athena, eCW, NextGen, and others. Phased onboarding so navigators can start billing PIN within 30 days of go-live.
Got questions? We've got answers
Everything you need to know about Medicare's Principal Illness Navigation (PIN) program and how Navigate Care helps your practice deliver — and bill — it.
Still have questions? Talk to usStand up your PIN program in 30 days.
In a 20-minute PIN readiness review we walk through your patient panel, your eligibility flow, and your navigator capacity — and show exactly where Navigate Care turns existing work into G0023 / G0024 revenue.