Who receives the payer payment?
The eligible billing practitioner or organization receives any supported claim payment under its payer arrangement. A code price is an allowed amount, not guaranteed collections.
Talk with us FOR YOUR PRACTICE
Oncology and serious-illness care
Distinguish managing a serious condition from helping a patient navigate the plan and barriers around it.
RELEVANT PATHWAYS
Programs to consider for your patients
PCM · Principal Care Management
Disease-specific management for one complex, high-risk chronic condition.
Patient example, requirements, and billingPIN · Principal Illness Navigation
Condition-specific navigation with trained personnel and practitioner oversight.
Patient example, requirements, and billingCCM · Chronic Care Management
Broader coordination when multiple conditions and the CCM model independently fit.
Patient example, requirements, and billingHow to choose—and what must be verified
Consider PCM for a qualifying complex cancer-related condition needing disease-specific management, or PIN for barriers to a qualifying serious-illness treatment plan. Clinical management and navigation have different jobs and evidence.
A navigator is not a substitute for clinical management. Serious illness alone does not establish every program, and any overlapping services need independent eligibility and nonduplicated work.
PAYMENT & FINANCIAL PICTURE
How would payment and practice costs work?
The eligible practitioner bills supported PCM or PIN services, subject to their distinct rules and payer terms. PrimeVital is paid through its agreement; navigation personnel do not independently bill Medicare PIN.
What does PrimeVital charge?
PrimeVital’s operational fee is set in a written agreement. The practice also plans for clinician review, any device expense, patient cost sharing and unsuccessful claims.
The treating practitioner may bill a qualifying Part B service—not automatically the facility or agency.
Check enrollment, the exact service, stay dates, place of service and existing services. A Part A stay and care after discharge are different situations.
- Forecast PCM and PIN only for their separately supported work under applicable payer and billing rules. Do not count one task or minute twice.
- Include practitioner review, trained navigator or care-team costs, documentation, failed outreach, and support fees. A referral or resource list alone is not the complete payable service.
Illustrative PIN model
These starting figures are hypothetical. They are not Medicare rates, a PrimeVital quote, or a payment forecast. PrimeVital pilot terms are not modelled automatically. Replace them with your verified contract, service mix, and cost assumptions.
Estimate net after your agreed service fee and other costs
Enter the total fees from your written agreement. No fee is prefilled. Pilot service fees are paid from collections; treatment of denied or insufficient collections must be agreed before launch.
Leave at zero if already included in the service fee. Avoid counting it twice.
Shown separately from recurring operating costs.
35 of 50 patients meet the assumed service requirements.
Illustrative collections before service and practice costs: $3,500. This uses the hypothetical per-patient amount and collection rate above; it is not a code-specific Medicare estimate.
To estimate the amount remaining for the practice, open the cost section and enter the total service fee from a written proposal. We do not invent a PrimeVital price or show a misleading net amount before that is known.
Contribution is before other overhead and taxes. Actual billing uses service-level evidence and rules; this simplified model does not select codes, approve eligibility, or guarantee outcomes. Patient cost sharing and QMB protections must be checked separately.
THE WORKING PROCESS
Keep treatment decisions and navigation connected
An illustrative operating workflow. Agree on the exact roles, clinical protocol, records, and service scope before launch.
- 1
Define the treatment need
Oncology practitioner
Assess the patient and establish the appropriate condition-specific care or serious-illness treatment plan.
- 2
Identify barriers and roles
Patient + clinical team + navigator
Record medication, transport, language, appointment, or resource barriers. Assign each task to qualified personnel and complete enrollment requirements.
- 3
Carry out assigned work
Agreed care team or trained navigator
Support the plan and resolve assigned access barriers. Record who did what; clinical management and navigation are tracked separately.
- 4
Escalate clinical changes
Oncology practitioner
Assess symptoms or medication concerns and make treatment decisions. A navigator routes clinical issues rather than independently changing treatment.
- 5
Review completion and claims
Clinical + billing leads
Confirm qualifying services and time, exclude duplicated work, and review completed referrals, treatment access, patient goals, and collections.
Your first step
Choose a patient group and identify its main need: clinical management, treatment-access barriers, or both. Name the oncology lead and any navigator, then verify consent, initiating services, supervision, and nonduplicated work.
EXAMPLES FOR YOUR SETTING
Start with a real need in your practice.
These scenarios show what to evaluate, rather than automatically assign a program or approve reimbursement.
Complex treatment changes
Assess PCM around the disease-specific plan and required management.
Transport and caregiver barriers
Assess PIN to help the patient access planned treatment and return clinical questions to the team.
ONE ILLUSTRATIVE PIN JOURNEY
See the patient, practitioner, and support roles.
Meet Denise: cancer treatment involves several appointments, transport difficulties, and questions her caregiver cannot easily resolve.
Identify the need
Initiating visit- Patient / caregiver
- Discusses the illness, barriers, consent, and costs.
- Treating practice
- Performs the qualifying visit and establishes the condition-specific plan.
- PrimeVital’s agreed role
- Helps map navigation needs and the agreed support arrangement.
- What gets recorded
- Qualifying serious condition, visit, plan, and consent.
The sample goal
Help Denise complete the treating team’s plan and bring clinical questions back to that team.
YOUR INVOLVEMENT
Agree on responsibilities before the first patient starts.
Your organization
The treating practitioner owns the disease plan, clinical decisions, escalation, and final claims. Navigation personnel help with access and understanding.
PrimeVital’s agreed support
The agreed care-management team can support coordination and evidence handoffs. Navigation tasks and personnel training would be confirmed for the specific PIN engagement.
Service hours, professional qualifications, technology, integrations, records access, and fees are confirmed in the engagement. Front-desk automation handles agreed administrative tasks; clinical judgment and claims remain with the responsible qualified professionals.
WHAT YOU NEED TO DO
A practical launch checklist.
- Identify the condition, risk, initiating visit, consent, and responsible practitioner.
- Separate treatment management from navigation tasks.
- Confirm navigator training and clinical staff qualifications.
- Track eligible work and time without duplicating other programs.
- Check payer, hospice or other setting-specific arrangements before selecting a pathway.
COMMON OWNER QUESTIONS
Resolve these before committing.
Does the navigator manage cancer treatment?
The treating oncology professional owns treatment. Trained navigation personnel help overcome barriers to that plan under the required direction and supervision.
Does every patient with cancer qualify?
No. The chosen service has its own clinical and service requirements. Diagnosis alone does not establish PCM or PIN payment.
BENEFITS TO TRACK
Choose a baseline and a review date.
Agree on the measures that matter to your patients and team.
- Treatment appointments completed
- Barriers resolved
- Clinical questions handed back and closed
- Patient and caregiver understanding
Sources and scope
Reviewed October 7, 2026. Practice type alone does not establish clinical eligibility or payment. Detailed program pages maintain the code references; use the patient’s actual payer, professional, setting, and date of service.
YOUR PRACTICE, YOUR PATIENTS
Bring us the workflow you want to improve.
Share your practice type, patient group, payer mix, and current team. We can map the care pathway, available support, launch gaps, and assumptions to verify.
DESIGN A PRACTICAL STARTING POINT
Tell us where the workflow is breaking. We’ll show you where to begin.
Send us a message
Continue on your phoneScan to open a pre-addressed email draft.Email contact@theprimevital.com