CurrentAnthemPolicy CABC-CD-041584-23

Community Health Worker (CHW) services coverage criteria

Defines covered Community Health Worker services (preventive services including health education, navigation, screening, advocacy, violence prevention, and asthma preventive services) for Anthem Blue Cross members, and explains provider contacts and referral processes.

Policy Summary

PayerAnthem

PolicyCommunity Health Worker (CHW) services coverage criteria

Policy CodePolicy CABC-CD-041584-23

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain a written recommendation from a physician or other licensed practitioner within their scope of practice before providing CHW services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6covered service types

1written recommendation required

NCapplicable state

Coverage Criteria for CHW Services

Medically Necessary CHW Services

Covered when services are preventive and a written recommendation is provided by a licensed practitioner; may be targeted to beneficiaries with risk factors or needs.

General coverage conditions: CHW services are considered medically necessary for beneficiaries with one or more chronic health conditions (including behavioral health) or exposure to violence and trauma, who are at risk for a chronic health condition or environmental health exposure, who face barriers meeting their health or health-related social needs, and/or who would benefit from preventive services.one or more of the listed risk conditions

Requires written recommendation by a physician or other licensed practitioner within their scope of practice under state law.

Covered service types: Health education; Health navigation; Screening and assessment; Individual support or advocacy; Violence preventive services; Asthma preventive services (APS).N/A

APS provided only by qualified/certified CHWs; unqualified CHWs may not provide asthma education or in-home environmental trigger assessments.

Policy Summary

PayerAnthem

PolicyCommunity Health Worker (CHW) services coverage criteria

Policy CodePolicy CABC-CD-041584-23

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain a written recommendation from a physician or other licensed practitioner within their scope of practice before providing CHW services.

SourceLink

On This Page

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Covered Codes and Services

Covered Codes/Services (descriptive list)mixed

Health education	Promotes the members' health, or address barriers to physical and mental healthcare, including providing information or instruction on health topics; may include coaching and goal setting to improve self-management.
Health navigation	Provides information, training, referrals, or support to assist beneficiaries to access healthcare, understand the healthcare system, engage in their own care, connect to community resources, serve as a cultural liaison, assist licensed providers with care plans, outreach and resource coordination, and help enroll or maintain enrollment in assistance programs when provided pursuant to a plan of care.
Screening and assessment	Non-licensed assistance to connect a beneficiary to appropriate services to improve their health.
Individual support or advocacy	Assists a beneficiary to prevent the onset or exacerbation of a health condition or preventing injury or violence.
Violence preventive services	Evidence-based, trauma-informed, and culturally responsive preventive services provided by a qualified individual to reduce incidence of violent injury or reinjury, promote trauma recovery, stabilization, and improved outcomes.
Asthma preventive services (APS)	Assists with health education and navigation; provides information about asthma basics, proper medication use, evidence-based self-management techniques and self-monitoring skills, and actions to mitigate or control environmental exposures that exacerbate asthma.

Provider Actions and Referral Requirements

Documentation Required

Provider Actions and Referral Requirements

Services require a written recommendation by an authorized licensed practitioner. Community Health Worker (CHW) services must be recommended in writing by a physician or other licensed practitioner of the healing arts within their scope of practice under state law before CHW services are provided.

Written practitioner recommendation required: A physician or other licensed practitioner must provide a written recommendation within their scope of practice before CHW services are initiated.
Referrals: Use the Care Management Referral Form to refer members for CHW services.
Contact for referrals and provider enrollment: Call Anthem Blue Cross at 800-407-4627 (TTY 711) for members outside L.A. County or 888-285-7801 (TTY 711) for members inside L.A. County. The Care Management Referral Form can be emailed or faxed and is available at https://tinyurl.com/mpj55dth.
Becoming a CHW provider: For information about becoming a CHW provider, contact CalAIMCHW@anthem.com.

Background

Community Health Worker (CHW) services are offered as preventive health services intended to prevent disease, disability, and other adverse health outcomes and to promote physical and mental health. CHWs — who may be known by a variety of job titles — provide a range of services that address chronic disease prevention and management, behavioral health and substance use, perinatal care, violence prevention, environmental and climate‑sensitive health issues, and social determinants of health. CHW services are considered medically necessary for beneficiaries with one or more chronic health conditions (including behavioral health) or exposure to violence and trauma, those at risk for chronic or environmental health exposures, those facing barriers to meeting health or health‑related social needs, and/or those who would benefit from preventive services. These services require a written recommendation by a physician or other licensed practitioner within their scope of practice under state law.

Definitions

CHW — definition and alternate names for Community Health Workers

DefinitionCommunity Health Workers (CHWs) are non-licensed public health workers who provide preventive health services to prevent disease, disability, and promote physical and mental health.

Alternate job titlesAlso known as promoters, community health representatives, health navigators, and other non‑licensed public health workers.

Scope of servicesProvide health education, health navigation, screening and assessment, individual support/advocacy, violence preventive services, and asthma preventive services.

LicensureCHWs are non‑licensed personnel who may serve as cultural liaisons or assist licensed healthcare providers as part of a care team.

LimitationsUnqualified/uncertified CHWs may not provide asthma education or in‑home environmental trigger assessments.

VPP — Violence Prevention Professional definition and certification pathways

DefinitionViolence Prevention Professional (VPP) — a designation for individuals providing CHW violence prevention services who meet specified training or certification requirements.

Certification pathwaysVPP certification issued by Health Alliance for Violence Intervention.

Alternative training pathwayCertificate of completion in gang intervention training from the Urban Peace Institute qualifies as an alternative to VPP certification.

Applicable service areaRequired only for individuals providing CHW violence prevention services.

OpenPayer

Community Health Worker (CHW) services coverage criteria

Coverage Criteria for CHW Services

Covered Codes and Services

Provider Actions and Referral Requirements

Background

Definitions

Revision History