Community Health Worker

A community health worker (CHW) is a trained health educator who works with PrimeWest Health members. CHWs have a close understanding of the communities they work in and have close ties with local community service providers. CHWs assist individuals and communities with adopting healthy behaviors, provide members with information on available resources, provide social support and informal counseling, advocate for individuals and community health needs, and act as a liaison between providers and members.

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

Eligible Providers

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

Currently enrolled CHWs must inform the Minnesota Department of Human Services (DHS) of their affiliation with dentists, Advanced Practice Registered Nurses (APRNs), certified Public Health Nurses (PHNs), or mental health professionals via the Minnesota Provider Screening and Enrollment (MPSE) Portal or by completing and faxing a signed MHCP Individual Provider Profile Change (DHS-3535) form.

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 non-pay providers, and services must be billed as an eligible PrimeWest Health-enrolled billing provider to receive payment.

Enrollment Criteria

In addition to MHCP enrollment, PrimeWest Health requires CHWs to enroll in order to be represented on a claim as the provider who provided the services. During the MHCP enrollment process, MHCP assigns the CHW a Unique Minnesota Provider Identifier (UMPI) if the CHW does not have a National Provider Identifier (NPI).

CHWs interested in enrolling must submit the following signed and completed forms:

1. Network Information Request Form
2. MHCP Applicant Assurance Statement (DHS-5308)
3. MnSCU CHW certification to the application form.
4. Ownership Disclosure
5. Certificate of General Liability Insurance
6. MHCP Welcome Letter

Email completed documents to contracting@primewest.org.

Eligible Billing Providers

1. Advance practice registered nurse (APRN)
2. Clinic
3. Community health clinic
4. Critical access hospital
5. Dentist
6. Family planning agency
7. Federally qualified health centers (FQHC)
8. Hospital
9. Indian health service (IHS) facility
10. Mental health professionals
11. Physician
12. Public health nurse clinic
13. Rural health clinics (RHC)
14. Tribal health facility

Eligible Members

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

Covered Services

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

1. PrimeWest Health requires general supervision by a PrimeWest Health-enrolled physician, APRN, dentist, mental health professional, non-enrolled certified public health nurse, or registered nurse working for an enrolled organization.
2. A physician, APRN, dentist, certified public health nurse, or mental health professional must order the education service(s) and must order that a CHW provide the service(s).
3. The service must involve teaching a member how to self-manage his/her health or oral health effectively in conjunction with the health care team.
4. The service must be provided face-to-face with the member (individually or in a group) in an outpatient, home, clinic, or other community setting.
5. The content of the education plan or training program must be consistent with established or recognized health or dental health care standards. The curriculum may be modified as necessary for the clinical needs, cultural norms, and health or dental literacy of the member.

Noncovered Services

PrimeWest Health 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:

1. An order for services signed by a PrimeWest Health-enrolled physician, APRN, dentist, mental health professional, or public health nurse working for an enrolled organization. The order must specify the number of units ordered and whether group or individual services were provided.
2. Documentation of the member education plan or training program used by the CHW
3. Documentation of periodic assessment of the member’s progress and need for ongoing CHW services
4. Documentation of the following:
   1. Date of service
   2. Start and end time for the service
   3. Whether the service was group or individual and, if group, number of members present, a summary of the session’s content, and the CHWs signature and printed name

Billing

Eligible billing providers must submit claims for the rendering CHW providers’ services.

Submit claims electronically using the 837P format and do the following:

1. Use the National Provider Identifier (NPI) of the hospital, clinic, physician, APRN, public health nursing organization, or mental health professional as the billing provider
2. Use the following procedure codes:
   1. 98960: self-management education and training, face-to-face, 1 patient
   2. 98961: self-management education and training, face-to-face, 2 – 4 patients
   3. 98962: self-management education and training, face-to-face, 5 – 8 patients
   4. For groups with more than 8 patients, use 98962 with the U9 modifier
3. Bill in 30-minute units: limit four units per 24 hours; no more than twenty-four units per calendar month, per member
4. Bill separate lines for each day service is provided (only one calendar month of service per claim)
5. Enter appropriate diagnosis
6. Use CHW non-pay Unique Minnesota Provider Identifier (UMPI) or NPI as rendering or attending provider
7. If the billing provider is not the same as the ordering provider, the billing provider must meet the same documentation requirements listed above. The documentation must support the number of units billed.

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

• G0019: Community health integration services performed by certified or trained auxiliary personnel, including a CHW 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 evaluation and management (E&M) visit must be billed before providing this service. The provider determines medical necessity as well as assess and identifies the SDOH that interfere with the diagnosis and treatment plan of the member. The services may be rendered by a CHW and billed under the provider who initiates the service.
  • Only one practitioner may bill for community health integration services per month, and that practitioner must be the same practitioner that bills for subsequent community health integration services.
  • CHWs must bill G0019 and G0022 following MHCP Medicare and Other Insurance billing policy.

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

All CHW services require supervision. Enter claim level supervising provider NPI number in loop ID 2310D, segment NM1, element NM109, and supervising provider identification or service line level in loop 2420D, segment NM1, element NM109, Supervising Provider Identification.

Federally qualified health centers (FQHC) and rural health clinics (RHC): Bill using appropriate electronic claim format.

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Updated_09/05/2024