For physicians, practices and partners
Your patients’ practical barriers, handled. With a Medicare pathway that pays for it.
You already know which patients this is for: the ones whose care plan is sound and whose life keeps getting in the way of it. Community Health Integration lets a dedicated navigator take on the rides, the equipment paperwork, the benefits and the follow-ups, and report back to you.
Who to refer
The patients you already worry about between visits.
CHI is for Medicare patients with an unmet social need that is interfering with the diagnosis or treatment of a medical problem. In practice, that looks like this.
- Medicare patients whose appointments, referrals or follow-ups keep slipping for practical reasons.
- Patients recently discharged who need home health, equipment or follow-ups coordinated.
- Patients with transportation, food, housing, utility or caregiver-support needs that are affecting their care.
- Patients with a new serious diagnosis whose family is overwhelmed by the logistics.
- Patients for whom a doctor-recommended walker, wheelchair, oxygen or hospital bed has stalled in paperwork.
- Dual-eligible patients who are not using the Medicaid and community benefits they qualify for.
How referral works
Four steps. Almost none of them are yours.
You refer, in under two minutes
Send the form below and we call your office back, or fax us directly. We take the patient details through a secure channel and confirm Medicare eligibility before anyone contacts the patient.
We reach the patient, with their consent
We call the patient or the family contact you identify, explain the service, check coverage, state any expected cost and ask permission to begin. Nothing starts without the patient’s yes.
A dedicated navigator does the work
One person, assigned to the patient, coordinates appointments, referrals, equipment, benefits, home support and everyday needs, and communicates with your office as an authorized contact.
You get a summary, not more work
A concise update to your office at agreed intervals and whenever something clinically relevant surfaces: a missed follow-up, a medication discrepancy, a fall. You decide the cadence and the channel.
The benefit
Community Health Integration, briefly.
In the CY2024 Physician Fee Schedule, CMS created Community Health Integration services (HCPCS G0019 and G0022) to pay for work by auxiliary personnel, community health workers, navigators and similar staff, under the general supervision of a billing practitioner, to address social determinants of health that are significantly limiting a practitioner’s ability to diagnose or treat a medical problem.
The service follows an initiating E/M visit in which the practitioner identifies the unmet need and establishes that CHI is medically necessary. It is billed per calendar month, requires patient consent, and can be provided alongside chronic care management and transitional care management.
Navigate Care provides the navigator, the workflow, the documentation and the reporting. Your office provides the referral and a contact for updates.
Read our explainers: the codes and 2026 rates, Community Health Integration and PIN vs CHI.
Refer a patient
Tell us how to reach your office.
No patient details here. We call you back within one business day, take the referral securely and confirm eligibility before anyone contacts the patient.
Questions from practices
What does my office have to do?
Refer the patient and identify a contact for updates. Community Health Integration requires an initiating visit that establishes the unmet social need; in most cases a recent E/M visit with the treating practitioner qualifies and no additional visit is required. We handle consent, coverage checks, enrollment and the ongoing work.
Who bills Medicare, and does it affect my billing?
Community Health Integration (G0019, G0022) is billed under Medicare Part B by the practitioner overseeing the navigator. Depending on the arrangement, that may be your practice with Navigate Care providing the service under general supervision, or a Navigate Care practitioner. Either way, it does not conflict with your E/M, CCM or TCM billing. We walk your billing staff through it before the first patient.
What does the patient pay?
Standard Part B cost-sharing: deductible, then 20% coinsurance, which Medigap, Medicaid, QMB or retiree coverage usually covers in full. We confirm the amount with the patient before services begin and tell them if it will be anything other than $0.
Is this the same as care management (CCM) or transitional care (TCM)?
No. CHI addresses unmet social determinants of health that interfere with the treatment plan; CCM and TCM address clinical care coordination and may be billed in the same month. CHI is also distinct from Principal Illness Navigation, which addresses a serious high-risk condition. We help identify which applies to a given patient.
How do you protect patient information?
Navigate Care operates under HIPAA as a covered entity and signs Business Associate Agreements where the arrangement requires one. Referral details are exchanged only through secure channels, never through this web form. Patients control what is shared with family members.
Do you pay for referrals?
No. Navigate Care does not pay, and does not accept payment, for patient referrals. Referral is a clinical decision made in the patient’s interest, and the patient always retains the choice of provider.
Guides
Background reading for your team
Community Health Integration: help when daily life gets in the way of care
Food access, transport, or your living situation can make a care plan hard to follow. Medicare may cover coordination to help address those barriers.
PIN vs CHI: which Medicare navigation benefit fits?
Two benefits, four billing codes, one deciding question — is the obstacle the illness, or is it life around the illness? Here's how to tell, and what to ask for.
Principal Illness Navigation: eligibility, costs, and getting help
A serious illness can leave you managing appointments, referrals, and questions between visits. Medicare may cover a navigator to help you find and follow the care you need.
The social side of health: why a missing ride undoes good medicine
Where someone lives, what they eat, whether they can get across town — these decide outcomes more than most treatments do. Medicare finally started paying attention.
Chronic Care Management: the monthly benefit hiding in plain sight
If your parent has two or more chronic conditions, Medicare will pay a practice to coordinate between visits — including a number you can call at 2am. Most people are never offered it.
Why the US needs healthcare navigation
US healthcare has never been more advanced — and never been harder to reach. The fix has a name, decades of evidence, and now a place in Medicare.