Alvee Health | SDOH and Whole-Person Care, Activated

How It Works

Let Alvee do what your team never has time for.

Alvee surfaces what your team can’t get to, reaches patients between visits, and captures the revenue. No added steps. Automation where it’s routine, a human where it counts.

The answers are already in the chart.

No new screeners. No new workflows. Alvee reads your notes, assessments, and history, surfaces every barrier, and auto-codes it to ICD-10, before your team opens the encounter. It catches what hand-screening misses.

Patients get connected. Not just referred.

A referral is a pamphlet. A connection is a patient enrolled in SNAP, a ride booked, a follow-up that happens. Alvee builds the care plan in clicks and matches resources to real needs. Between visits, the Autonomous Care Navigator handles enrollment and follow-up by voice and text, around the clock.

Get paid for the care you already provide.

Your team is already doing the work. Alvee captures the time, writes the documentation, and produces compliant claims: CHI, PIN, CCM, PCM, G0136, and more. For FQHCs, all paid outside the PPS rate.

Platform

Make the invisible visible.Then act on it.

One click. Every code, referral, and note. Done.

Every Z-code, billing code, CHI/PIN/CCM referral, and clinical action, packaged into one approval that writes back to your EHR. A few seconds of review. A connection that can change someone’s week, or their year.

Z-codes to the problem list; E/M upgrades and care-coordination codes (including G0136) to charge capture
CHI, PIN, and CCM referrals with built-in consent workflows
Social-risk actions mapped to evidence and documented in the progress note
Full audit trail: provider name, timestamp, every action recorded

One-Click Approve packaging Z-codes, billing, referrals, and notes

Every barrier. Every note. Automatically.

ValidatedDocumentedNeeds Assessment

Scans notes, assessments, and flowsheets for social and health barriers, each mapped to the right ICD-10 Z-code. This is where the 21.5× comes from, validated across 402K visits with a top-5 health system.

21.5× more social needs surfaced than standard Z-code workflows
19+ barrier types: housing, food, transportation, employment, isolation, and more
Clinician review at every step

Social determinants of health (SDOH) extractor: documented patient barriers list with auto-mapped Z-codes

Care plans in clicks, not hours.

The Care Plan Wizard turns the patient’s data into problems, goals, interventions, and a summary. Add instructions. Review. Approve.

Works across primary care, inpatient, oncology, and maternal health
Adapts to patient context and learns your preferences
Full wizard with clinician oversight at each step

Care Plan Wizard generating problems, goals, and interventions

Every billable minute, captured.

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Tracks billable time across CHI, PIN, CCM, and PCM, flags which claims are ready, and writes the documentation. Your team focuses on patients. Alvee makes sure it counts.

Tracks CHI/PIN, CCM (99490/99439), and PCM (99426/99427)
Auto-generates claims when billing thresholds are met
Manager dashboard: hours, patients, revenue

Navigator dashboard tracking billable CHI, PIN, CCM, and PCM time

The right resource, matched in seconds.

Matches patients to local services by need, location, and eligibility, then tracks whether the connection was made. No more manual searching.

AI recommendations from documented barriers
Capacity data and quality ratings
Closed-loop referral tracking

Resource Matching surfacing local services by need, location, and eligibility

Age-Friendly 4Ms, handled before the visit.

A voice AI agent for the IHI Age-Friendly 4Ms. It calls patients 65+, captures what matters most to them, and delivers a 4M summary to the care team. Phone-based. No app required.

Cuts 4M documentation from 45–60 min to 10–15
Co-developed with leading health systems
Supports CMS Age-Friendly attestation

Age-Friendly 4M Summary produced by the What Matters voice agent

The Business Case

The economics of care have changed. Your workflows haven’t.

Margins are tighter. Medicaid coverage is less stable. Care teams are stretched. Social needs are driving utilization, quality gaps, missed revenue, and patients falling through the cracks.

Alvee turns fragmented social care work into measurable return: revenue captured, hours saved, patients retained, referrals closed, and outcomes improved.

The problem is not that teams are not doing the work. The problem is that the work is too manual to scale, too fragmented to track, and too often undocumented when it matters.

Without Alvee

Social care stays trapped in spreadsheets, referral portals, inboxes, call notes, and manual follow-up. The work happens, but the value is lost.

With Alvee

Alvee identifies who needs help, automates outreach and follow-up, guides care teams through the next best action, tracks every referral to closure, and documents the work needed to prove impact.

That is how social care becomes measurable, scalable, and financially sustainable.

The ROI shows up everywhere care breaks down.

Revenue captured$250K+per 100 enrolled patients, annually

Revenue you are already earning, but may not be capturing

Whole-person care, navigation, and care coordination work is increasingly reimbursable, but only if teams can identify eligible patients, document the work, track time, and support compliant billing. Alvee turns invisible work into captured revenue.

Workforce scaled10+ hoursback per navigator, every week

Scale your team without adding headcount

Care teams are buried in documentation, outreach, reminders, referral tracking, and follow-up. Alvee automates the repetitive work so navigators, CHWs, and care managers can focus on the patients who need human support most.

Coverage protected~69%of Medicaid disenrollments are procedural

Protect coverage before patients fall off

When eligible patients lose Medicaid because of paperwork, providers lose billable visits, plans lose members, and patients lose access. Alvee flags coverage risk and automates the outreach needed to keep people connected to care.

Utilization avoided$2.47returned per $1 spent

Close needs before they become costly events

Unresolved social needs show up later as missed appointments, uncontrolled chronic disease, avoidable ED visits, and hospitalizations. Alvee helps teams intervene earlier, close the loop, and prove what happened.

Quality improvedSNS-Eplus value-based performance

Move from screening to measurable intervention

Screening alone does not improve outcomes or move quality measures. Alvee documents the full path from identified need to intervention to resolution, supporting HEDIS, Stars, pay-for-performance, and value-based care goals.

One platform. Multiple returns.

For providers & FQHCs

Capture reimbursable services
Reduce uncompensated work
Keep patients covered
Free up care teams
Document what happened

For health plans & at-risk groups

Improve member engagement
Reduce avoidable utilization
Support gap closure
Improve retention
Prove which interventions are working

For patients

Fewer dead-end referrals
More timely help
Better continuity
A care team that can actually follow through

Figures reflect Medicare fee-for-service unless noted. The ~$250K assumes roughly 100 patients at about $207 to $210 per patient each month (the ongoing-navigation-and-chronic-care tier), using CY2026 Medicare Physician Fee Schedule final-rule rates; a stable, single-need patient runs lower and a complex one higher. Actual billing reflects time spent, medical necessity, and documentation, and not every patient qualifies for every code. The hours-back figure reflects results from current Alvee deployments. ~69% procedural disenrollment: KFF Medicaid Enrollment and Unwinding Tracker. $2.47 per $1: Kangovi et al., Health Affairs, 2020 (Medicaid community health worker randomized trial). SNS-E is NCQA’s HEDIS Social Need Screening and Intervention measure.

Revenue and savings are only the starting point.
The real return is fewer people falling through the cracks.Alvee helps organizations turn social care from a manual burden into a measurable system of action.

Reimbursement calculator

Start with the revenue you can quantify today

Medicare now reimburses for whole-person care activities many teams are already doing, including care coordination, navigation, follow-up, and support for patients with complex needs. Use the calculator to estimate the reimbursable revenue opportunity in your panel.

Estimate your reimbursement

Why Now

Every month you wait, needs go unseen. And unseen needs get expensive.

Most of what drives health, the social determinants of health (SDOH), sometimes called upstream drivers of health or social drivers of health, happens outside the exam room. Alvee activates them inside your existing workflow.

CMS expanded reimbursement for care coordination and whole-person care. The funding is there. The evidence is there. What’s missing is the infrastructure to operationalize it. Every month without it is a patient who didn’t get help, and revenue you won’t get back.

Patient Outcomes

Seeing the whole patient changes the outcome. CMS proved it.

In CMS’s Accountable Health Communities Model, its largest test of social-needs navigation, beneficiaries who got navigation had 9% fewer ED visits and fewer admissions. The key finding: patients handed only a resource list saw no change. Screening finds the need. Navigation changes the outcome. Alvee does both.

A resource list doesn’t reduce ED visits. Active navigation does, at scale.

Reimbursement

CMS expanded the billing. Most organizations still can’t capture it.

CHI, PIN, CCM, PCM. The codes exist, and the 2026 PFS expanded who can bill. The gap was never the codes. It’s operationalization. That’s what Alvee does.

Automated documentation, time tracking, and claim generation. Built in.

FQHC Opportunity

Real revenue, outside the PPS rate.

CHI, PIN, CCM, and PCM pay at national PFS rates, separate from your PPS payment. Net-new revenue, without displacing a dollar of existing billing.

Incremental revenue your FQHC isn’t capturing today.

Do what matters most.Let Alvee handle the rest.