Community Health Worker (CHW)

Revised: February 14, 2024

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Noncovered Services

· Billing

· Definitions

· Legal References

Overview

A community health worker (CHW) is a trained health educator who works with Minnesota Health Care Programs (MHCP) members who may have difficulty understanding providers due to cultural or language barriers. CHWs extend the reach of providers into underserved communities, reduce health disparities, enhance provider communication, and improve health outcomes and overall quality measures. Working in conjunction with primary care providers, CHWs can bridge gaps in communication and instill lasting health knowledge.

CHW services are a diagnosis-related medical intervention, not a social service.

CHWs providing diagnosis-related patient education services to enrollees of managed care organizations (MCOs) must contact the MCOs for enrollment requirements and coverage policies.

CHW services that provide patient education for health promotion and disease management are covered if provided under the supervision of a physician, dentist, advanced practice registered nurse (APRN), certified public health nurse (PHN), mental health (MH) professional or registered nurse.

Eligible Providers

Providers must have a valid certificate from the Minnesota State Colleges and Universities demonstrating that the applicant has completed an approved community health worker curriculum. CHW providers must enroll and be screened following the MHCP provider screening requirements at the time of enrollment and once within every five years to maintain their enrollment.

Currently enrolled CHWs must inform the Minnesota Department of Humans Services (DHS) of their affiliation with dentists, ARPNs, certified PHNs or mental health professionals by requesting the affiliations using the Minnesota Provider Screening and Enrollment (MPSE) Portal or by completing, signing and faxing DHS the MHCP Individual Provider Profile Change (DHS-3535) (PDF).

MHCP requires CHWs to enroll so they are represented on a claim as the provider who provided the services. During the enrollment process, Provider Eligibility and Compliance will assign the CHW worker a Unique Minnesota Provider Identifier (UMPI) if the CHW does not have a National Provider Identifier (NPI).

Enrolled CHWs are considered a non-pay-to provider but must be listed on the claim as the individual who rendered the CHW services. CHWs must provide an eligible MHCP-enrolled billing provider with their UMPI or NPI, so the eligible billing provider can submit claims for their services.

Eligible Providers

· Advance practice registered nurse (APRN)

· Clinic

· Community health clinic (CHC)

· Critical access hospital

· Dentist

· Family planning agency

· Federally qualified health centers (FQHC)

· Hospital

· Indian health service (IHS) facility

· Mental health professionals

· Physician

· Public health nurse clinic (PHNC)

· Rural health clinics (RHC)

· Tribal health facility

Eligible Members

Medical Assistance (MA) and MinnesotaCare members are eligible to receive education services provided by a CHW.

MHCP members enrolled in the Minnesota Family Planning Program (MFPP) are not eligible to receive CHW services.

Covered Services

MHCP will cover diagnosis-related patient education services, including diabetes prevention and pediatric obesity treatment provided by a CHW with the following criteria:

· MHCP requires general supervision by an MHCP-enrolled physician, APRN, dentist, mental health professional, non-enrolled certified public health nurse or registered nurse working for an enrolled organization

· A physician, APRN, dentist, certified public health nurse or mental health professional must order the patient education service(s) and must order that a CHW provides the service(s)

· The service involves teaching the patient how to self-manage his or her health or oral health effectively in conjunction with the health care team

· The service is provided face-to-face with the member (individually or in a group) in an outpatient, home, clinic or other community setting

· The content of the patient education plan or training program is consistent with established or recognized health or dental health care standards. Curriculum may be modified as necessary for the clinical needs, cultural norms and health or dental literacy of the individual patients

Noncovered Services

MHCP does not cover social services such as enrollment assistance, case management or advocacy delivered by a CHW.

Required Documentation

The CHW education service is based on units of time. Include the following in the member’s record:

· An order for services signed by an MHCP-enrolled physician, APRN, dentist, mental health professional or non-enrolled registered nurse or public health nurse working for an enrolled organization. The order must specify the number of units ordered and whether group or individual services

· Documentation of the patient education plan or training program used by the CHW

· Documentation of periodic assessment of the member’s progress and need for ongoing CHW services

· Documentation of the following:

· Date of service

· Start and end time for the service

· Whether the service was group or individual and if group, number of patients present, summary of the session’s content, and the CHWs signature and printed name

Billing

An eligible billing provider must submit claims for the rendering CHW provider’s services.

Follow these guidelines when submitting claims for CHW services:

· Submit claims electronically using the Professional (837P) claim form

· Use the hospital’s, clinic’s, physician’s, APRN’s, public health nursing organization’s or mental health professional’s NPI as the pay-to provider

· Use the following procedure codes:

· 98960 self-management education and training, face-to-face, 1 patient

· 98961 self-management education and training, face-to-face, 2–4 patients

· 98962 self-management education and training, face-to-face, 5–8 patients

· For groups with more than 8 patients, use 98962 with the U9 modifier

· Bill in 30-minute units: limit 4 units per 24 hours; no more than 24 units per calendar month per member

· Bill separate lines for each day service is provided (only one calendar month of service per claim)

· Enter appropriate diagnosis

· Enter the non-pay-to provider’s UMPI or NPI of the CHW, who provided the services, as the rendering provider

· When appropriate, enter the UMPI or NPI of the provider who wrote the order and signed for the services, as the ordering provider

CHWs may also bill the following procedure codes for community health integration services. Follow Medicare guidance about the following services that may be performed by CHWs.

· G0019: Community health integration services performed by certified or trained auxiliary personnel, including a community health worker that is under the direction of a physician or other practitioner. The services may be billed for 60 minutes per calendar month in the following activities to address social determinants of health (SDOH) needs that are significantly limiting the ability to diagnose or treat needs addressed in an initiating visit.

· Needs that are addressed in an initiating visit may include, but are not limited to, the following:

· Person-centered assessment, performed to better understand the individualized context of the intersection between the SDOH needs and the needs addressed in the initiating visit;

· Conducting a person-centered assessment to understand patient’s life story, strengths, needs, goals, preferences and desired outcomes, including understanding cultural and linguistic factors and including unmet SDOH needs (not separately billed)

· Facilitating patient driven goal setting and establishing an action plan;

· Coordination of care transitions between and among health care practitioners and settings, including transitions involving referral to other clinicians;

· Facilitating behavioral change as necessary for meeting diagnosis and treatment goals, including promoting patient motivations to participate in care and reach person-centered diagnosis or treatment goals

· Providing tailored support to the patient as needed to accomplish the practitioner’s treatment plan;

· Facilitating access to community based social services (housing, utilities, transportation, food assistance) to address the SDOH need.

· G0022: Community health integration services, each additional 30 minutes per calendar month. List separately in addition to G0019.

· An E&M visit must be billed before providing this service. The practitioner will determine medical necessity as well as assess and identify the SDOH that interfere with the diagnosis and treatment plan of the member. The services may be rendered by CHW and billed under the provider who initiates the service.

· CHWs must bill G0019 and G0022 following MHCP Medicare and Other Insurance billing policy.

The billing provider must meet the same documentation requirements previously listed. The documentation must support the number of units billed.

Federally qualified health centers (FQHC) and rural health clinics (RHC): Bill using the appropriate electronic claim format found in the Billing section under FQHC and RHC under Clinic Services in the MHCP Provider Manual.

MCO

Providers must bill the person’s MCO for patient education services provided by a community health worker.

Definitions

Community health representative (CHR): Community-based health care providers who provide health promotion and disease prevention services in their communities, and have completed an Indian Health Service-funded, tribally contracted or granted, and directed program of training.

Community health worker (CHW): A health worker who is a trusted member or has an unusually close understanding of the community served, which enables the person to provide information about health issues that affect the community and link individuals with the health and social services they need to achieve wellness.

Legal References

Minnesota Statutes 256B.0625, subdivision 49 (Community health worker)
Minnesota Statutes 245.462, subdivision 18 (Mental health professional)
Minnesota Statutes 245.4871, subdivision 27 (Mental health professional)