Patient Access Map

Patient Access Map

The Hand-off from New Patient Coordination, Prior Authorization, Financial Navigation, through Patient Check-Out

3. Eligibility Check

5. Medical Record Intake

1. New Patient Referral

4. Nurse Navigation

2. Registration

12. Check-out

10. Financial Navigation

8. Schedule Consult

6. Prior Authorization

Now transitioning from NPC to Prior Auth and beyond

The next phase of the Patient Financial Acces journey —where coverage, cost, and care come together. Starting with Prior Authorization, each step represents a key action that ensures the patient is financially prepared, clinically supported, and scheduled for care. From receiving the payer’s decision to providing cost estimates, navigating financial support, and completing the consult, these steps close the loop with clarity and coordination.

11. Check-in

9. Provide an Estimate

7. Payer Response

Medical Record Intake

Gather What Matters: Medical Records Intake

Timely and complete medical records are essential for clinical decision-making, prior authorization, and consult preparation—ensure all relevant documents are requested, received, collated and accessible to the clinical team. Clinical team may want to move forward before all records have been secured.

Insurance Verification: The Gatekeeper to Access

- Confirm that the patient’s insurance plan is currently active and valid for the date of service. - This includes checking for term dates, plan type, and whether the provider is in-network.

Verification of Active Coverage

- Determine if the specific service (e.g., oncology consult, imaging, infusion) is covered under the patient’s plan. - Identify any limitations, exclusions, or requirements such as referrals or prior authorizations.

Benefit and Service-Level Review

- Eligibility results directly affect cost estimates, prior authorization needs, and scheduling decisions. - If coverage is denied or unclear, the patient may need financial. counseling, alternative payment options, or resubmission with updated information.

Financial Impact and Next Step

Timing Impacts Care

Prior Authorization

- Submitting prior auth early is critical to avoid delays in scheduling and treatment. - Payer turnaround times vary, and urgent cases may require escalation or expedited review.

Initial Submission Starts the Clock

The prior authorization process often begins with a basic submission typically including referral details, diagnosis codes, and insurance information. All statuses and communications are retained in the WQs.

Authorization Status Shapes the Path Forward

- Approval allows scheduling and financial planning to proceed. - Denials or requests for more info trigger workflow detours—resubmission, appeals, or alternative coverage strategies.

Assess, Prioritize, and Prepare for Care

• The nurse navigator assesses the patient’s symptoms, diagnosis, and urgency to determine how quickly they need to be seen.
• This triage helps guide whether the patient should be scheduled for a standard consult, an expedited visit, or redirected for additional workup.

Clinical Prioritization

• The nurse navigator provides information on what additional clinical data should be collected, such as pathology reports, imaging history, or symptom progression.
• These insights are critical for scheduling, prior authorization, and preparing the oncology team.

Information Gathering

• Nurse navigator triage serves as a bridge between clinical intake and operational planning.
• The outcome of this step informs medical records intake, prior authorization strategy, and consult scheduling—ensuring the patient’s care path is clinically appropriate and logistically sound.

Care Coordination

new patient coordinator

NPC Referral WQ

A new patient referral is either created or is in the workqueue. The referral record is reviewed for completeness and urgency before moving forward. The patient's insurance is screened for OSV being in-network.

TThe New Patient Coordinator may have to contact the referring provider for clarity or additional information.

How will referrals that originate in Stanford and end up being an OSV referrals get to OSV?

Check-Out

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RTLS Badge Return

Provide AVS

The consult is complete—now it’s time to wrap up. During check-out the AVS is provided, a return visit is scheduled, the RTLS badge is collected, and mobility assistance is provided (if needed) to ensure a smooth and supported departure.

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03

Schedule Follow-Up Appointments

Mobility/Access Assistance

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Transporation Assistance

Is there Epic functionality set up that automates the creation of orders for labs, imaging, treatment, or follow-up appointments during provider wrap-up?

Initial Call & Registration

Kick Off the Care Journey

If patient's coverage is Out of Network, the NPC informs the Financial Navigator to do further coverage validation. If In-Network: The journey begins with the NPC's call and patient registration, where foundational patient information is gathered and the EHR record is created. This step sets the stage for all downstream coordination and ensures the patient is officially entered into the system.

- Collect patient demographics, account & insurance - Confirm referring provider and reason for visit - Provide intake forms and HIPAA documents

The New Patient Coordinator serves as the gateway to care at OSV, setting the tone for a patient experience rooted in compassion, trust, and excellence from the very first interaction.

Financial Navigation a core part of the OSV care model. By embedding financial support into the patient journey, OSV ensures that patients feel informed, protected, and confident as they begin treatment.

- Navigators advocate on behalf of patients when coverage is denied or unclear. - They may assist with appeals, coordinate peer-to-peer reviews, or work with payers to resolve complex billing issues. - Their goal is to reduce financial barriers and ensure patients receive the care they need.

Advocacy

- The navigator verifies insurance coverage, confirms benefits, and confirms prior authorizations are in place. - They assess whether the patient meets financial criteria for specific services and flag any gaps that could delay care. - This step ensures that the patient is financially “cleared” to proceed with treatment or consults.

Clearance

Financial Navigation

- Navigators identify and connect patients with financial assistance programs, grants, , manufacturer copay support, and assists with the charity care process . - They help patients apply for Medicaid, SSI, or hospital-based aid when applicable. - This proactive approach can significantly reduce out-of-pocket costs and stress.

Assistance

- Patients receive clear, personalized explanations of their cost estimates, insurance benefits, and billing processes. - Navigators help patients understand what to expect financially, empowering them to make informed decisions. - Education includes payment plan options, coverage limits, and how to avoid surprise bills.

Education

- Next Steps: - Inform the Care Team – Notify the oncology provider or MDC team that the authorization was denied. This ensures they’re aware before consult planning or treatment discussions. * Noted by status code - Route to Financial Navigator – Explore self-pay options, assistance programs, or alternate coverage strategies. - Initiate Appeal (if applicable) – Begin resubmission, peer-to-peer review, or escalation process. - Notes: - Document the denial reason and payer communication, update the status. - Coordinate with clinical staff to determine next steps, especially if urgent care is needed.

Denied

- Next Step: Proceed directly to Scheduling Consult. - Notes: Authorization is valid; confirm expiration date and any service limit.

Approved

- Next Step: Proceed to Scheduling, but flag any restrictions (e.g., limited visits, specific provider). - Notes: May require patient notification or clinical coordination. * Noted by status code

Approved with Conditions

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Check-In

Identity Verification

Demographic & Insurance Update

The patient has arrived for their oncology consult. Front desk staff confirm identity, update demographics, obtains necessary signatures, collects a copay if applicable, and issues an RTLS badge which notifies the care team of the patient's arrival. This step ensures a smooth handoff into clinical care.

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CoPay Collection

Consent & Forms

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RTLS

Provide the Estimate

Once the consult is scheduled, the Financial Navigator prepares and shares a personalized cost estimate with the patient. This estimate is based on the patient’s insurance coverage, the type of visit scheduled, and any anticipated services. Providing this information upfront helps the patient understand their financial responsibility, explore assistance options if needed, and fosters transparency and trust in the care process.

Who is responsible for generating this estimate? NPC, Fin Navigator, or either? What tool(s) or method will be used for communication between the Patient, NPC and Financial Navigator? Where in the patient's record will estimate be stored?

schedule the consult

Care Starts Here

Schedule the patient’s oncology or MDC consult. Coordinate with clinical teams and ensure the appointment aligns with authorization status.

Note: The ONN May schedule the consult during the triage call if no prior authorization is required.