CurrentmhnPolicy N/A

Community Health Workers and Supervising Provider Organizations — CHW services and supervising provider requirements

Defines CHW service definitions, minimum qualifications and certification pathways, supervising provider responsibilities, member eligibility, documentation requirements (written recommendation and plan of care), annual training, and billing/verification processes for members served by the payer in North Carolina.

Policy Summary

Payermhn

PolicyCommunity Health Workers and Supervising Provider Organizations — CHW services and supervising provider requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain and submit a written recommendation from an authorized licensed practitioner to initiate CHW services and document encounters per payer requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 hrsminimum annual CHW training

2,000 hrswork experience pathway

18 monthsmax period without certificate

30 minunit length

6 months

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

licensed review interval

98960–98962CHW codes for HEDIS

Coverage Criteria

Member Eligibility

Covered when ANY of the following eligibility criteria are met as determined by the recommending provider:

Member eligibility for CHW services: Diagnosis of one or more chronic health (including behavioral health) conditions, or a suspected mental disorder or substance use disorder not yet diagnosed; presence of medical indicators of rising risk of chronic disease (e.g., elevated blood pressure, elevated blood glucose, elevated blood lead or childhood lead exposure); one or more Adverse Childhood Events; known risk factors including domestic/intimate partner violence, tobacco use, excessive alcohol use, and/or drug misuse; results of SDOH screening indicating unmet health-related social needs (e.g., housing or food insecurity); one or more ED visits in the previous 6 months; one or more hospital inpatient stays (including psychiatric facility) in the previous 6 months or at risk of institutionalization; one or more detox stays within the previous year; two or more missed medical appointments within the previous 6 months; member-expressed need for health system navigation/resource coordination; need for recommended preventive services (immunizations, annual dental visit, well childcare).n/a

As listed in chunk 17

Violence Prevention Services Eligibility

CHW violence prevention services available when ALL of the following are determined by a licensed practitioner:

Violence prevention eligibility: Member has been violently injured as a result of community violence; or Member is at significant risk of experiencing violent injury as a result of community violence; or Member has experienced chronic exposure to community violence. Services are specific to community (e.g., gang) violence.n/a

From chunk 7

General CHW Coverage Criteria

Covered when ALL of the following are met

Written recommendation and scope: A written recommendation for CHW services is submitted to the MCP by a physician or other authorized licensed practitioner within their scope of practice under state law (accepted practitioner types include physician assistants, nurse practitioners, clinical nurse specialists, podiatrists, nurse midwives, licensed midwives, registered nurses, public health nurses, psychologists, LMFTs, LCSWs, LPCCs, dentists, registered dental hygienists, licensed educational psychologists, licensed vocational nurses, and pharmacists).

Requirement and acceptable recommending practitioner types from chunk 22

Concurrent enrollment restriction: Member is not concurrently enrolled in Enhanced Care Management (ECM).

Concurrent ECM enrollment disqualifies CHW enrollment (chunk 22).

Encounter documentation: CHW documents dates, time/duration, nature of service, and includes the CHW's NPI; documentation is accessible to the Supervising Provider and integrated into the Member's medical record for encounter reporting. Recommending providers with portal access should record the recommendation in the provider portal; providers without portal access may complete the recommendation form for upload by the CHW or Supervising Provider.

Covered when - CHW service criteria for HEDIS impact

Covered when CHW services meet measure-specific timing, documentation, and diagnosis requirements to satisfy HEDIS numerator criteria

Behavioral health follow-up after ED or hospitalization: CHW contacts member within specified time windows (within 7 days for ED visits or hospital discharge for mental illness; within 30 days for follow-up after positive depression screen) AND documents the relevant principal diagnosis (mental health disorder, intentional self-harm, or depression) AND bills using CHW service codes 98960–98962 as appropriate.7 days; 30 days

FUM and DSF/PND follow-up timing and diagnosis documentation requirements from chunks 39, 40, 42, and 43

Substance use disorder initiation and engagement (IET): CHW contacts member within 14 days of a new substance use disorder diagnosis to support initiation of treatment and assists to ensure two additional engagement visits within the specified engagement window (e.g., within 31–34 days of initiation); documentation must include the substance use disorder diagnosis when billing CHW service codes 98960–98962.14 days; engagement visits within ~31–34 days

IET initiation and engagement timing and documentation requirements from chunk 40

A Violence Prevention Professional (VPP) Certificate authorizes a CHW to provide violence prevention services only. CHWs who hold a VPP Certificate are limited to the scope of community violence–related activities specified by that certificate; provision of other CHW services requires qualification through the Work Experience Pathway or completion of a General Certificate.

The policy explicitly excludes certain activities from CHW coverage. Not covered as CHW services are: clinical case management or care management that requires a license, child care, chore services (including shopping and cooking), companion services, employment services, assistance enrolling in non–health‑related government benefits, delivery of medication or medical supplies, personal care/homemaker services, respite care, services that duplicate another covered Medi‑Cal service, socialization, coordinating/assisting with transportation, services to individuals not enrolled in Medi‑Cal, and other services that require a license. The policy also clarifies that CHW services are distinct from Peer Support Services covered under Drug Medi‑Cal and Specialty Mental Health programs.

For the HEDIS measure Follow‑Up After Hospitalization for Mental Illness (FUH), CHW activities can support numerator attainment only when the encounter documentation meets measure requirements and the CHW services are overseen by an appropriate licensed provider. Specifically, documentation should include the relevant behavioral health diagnosis and the supervising provider must be a licensed mental health provider for CHW‑documented services to impact the measure.

CHW services that would require a professional license, or that duplicate an existing covered Medi‑Cal service, are not payable as CHW services. Examples include licensed clinical case management and any other licensed scope activities; where another Medi‑Cal program already covers the service, CHW billing for that same service is not permitted.

The policy does not list additional explicit conditions labeled “not medically necessary” in this section beyond the stated exclusions. It reiterates that CHW services are distinct from other licensed services and from program‑specific benefits; for example, asthma prevention may be provided by licensed clinicians or by qualified unlicensed CHWs when they meet the referenced qualifications, but no separate "not medically necessary" criteria are specified here.

Coding and Measure Timing

Covered CHW procedure codes referenced for HEDISCPTCovered

98960	Education and training for patient self-management by non-physician provider, individual
98961	Education and training for patient self-management by non-physician provider, group (2-4)
98962	Education and training for patient self-management by non-physician provider, group (5-8)

CHW service CPT codes referenced in HEDIS numerator value setCPTCovered

98960	Education and training for patient self-management by non-physician healthcare providers (CHW service code referenced)
98961	Education and training for patient self-management by non-physician healthcare providers (CHW service code referenced)
98962	Education and training for patient self-management by non-physician healthcare providers (CHW service code referenced)

Unit length — billing unit

Unit length1 unit = 30 minutes

Units defined per Medi‑Cal Provider Manual referenceUnit definition referenced in plan of care summary for extended CHW services

Use in encounter documentationDocumented time/duration should support number of units billed (each 30-minute unit)

ADHD follow-up timing — initiation and continuation

ADHD initiation timingInitiation phase: at least one visit within 30 days of the first ADHD prescription

ADHD continuation & maintenance (C&M)C&M phase: two additional visits on different dates between 31 days and 9 months after the initial prescription

Provider Actions, Documentation & Oversight

Documentation Required

Plan of care required for extended services — written care plan requirement when member needs multiple ongoing CHW services or continued services after 12 units

For members who need multiple ongoing CHW services or continued CHW services after 12 units, a written plan of care must be completed by one or more licensed providers (this may include the recommending provider and/or other licensed providers affiliated with the CHW Supervising Provider). The ordering provider for the plan of care does not need to be the same provider who initially recommended CHW services or the Supervising Provider. CHWs may participate in drafting the plan of care in collaboration with the member's care team. A licensed provider must review the plan of care at least every six months and document progress toward objectives and continued medical necessity. If a significant change in condition occurs, amend or discontinue the plan as appropriate.

Plan must specify the condition being treated and be relevant to that condition
Include other health care professionals treating the condition or barrier
Contain written objectives addressing the recipient's condition/barrier
List specific services required to meet objectives, including frequency and duration of CHW services (units = 30 minutes; do not exceed provider's order)
Licensed provider review required at least every 6 months; amend for significant condition changes

Definitions

Community Health Worker (CHW) — definition & alternate titles

DefinitionCommunity Health Worker (CHW): non-licensed public health worker (may be called Promotores, Community Health Representatives, Navigators, violence prevention professionals) providing preventive health services with specified qualifications

Typical alternate titlesPromotores, Community health representatives, Navigators, Violence Prevention Professional (for violence-specific services)

Role overviewDelivers preventive services, health education, screening, navigation, outreach, and referral supports consistent with CHW scope and training

Supervising Provider — definition & responsibilities

DefinitionSupervising Provider: the organization employing or overseeing the CHW, responsible for ensuring CHWs meet qualifications, overseeing services delivered, and submitting claims; must be a licensed provider, hospital, outpatient clinic, LHJ, or community-based organization

Background

Community Health Worker (CHW) services are defined as preventive health services delivered to prevent disease progression, prolong life, and promote physical and mental health. CHWs provide health education, health navigation, coaching, and referral support for members with chronic conditions, rising risk indicators, social needs, or recent acute care utilization. These services may also include qualified unlicensed provision of asthma prevention interventions when CHWs meet the specified qualifications.

Policy Summary

Payermhn

PolicyCommunity Health Workers and Supervising Provider Organizations — CHW services and supervising provider requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain and submit a written recommendation from an authorized licensed practitioner to initiate CHW services and document encounters per payer requirements.

SourceLink

On This Page

Documentation and portal submission requirements from chunks 23, 24, and 25

Chronic disease support (AMR, HBD, CBP): CHW provides health education, health navigation, SDOH screening, coaching, and referrals to support medication adherence, HbA1c testing/control, BP control, and asthma medication ratio improvement; appropriate documentation and use of CHW codes can support HEDIS numerator attainment. Clinical thresholds referenced: AMR controller ratio >= 0.50; HbA1c control <8.0% (control) and >9.0% (poor); BP control <140/90 mm Hg.AMR >=0.50; HbA1c <8.0% / >9.0%; BP <140/90 mm Hg

Recommended CHW actions and clinical thresholds from chunks 45, 46, and 47

Perinatal or postpartum positive depression screen follow-up: CHW connects with pregnant or postpartum member within 30 days of a positive depression screen, may administer PHQ9 if indicated, and documents the depression diagnosis when billing CHW service codes to satisfy PND-E and PDS-E Follow-Up on Positive Screen numerators.30 days

PND-E and PDS-E follow-up timing and documentation requirements from chunks 42 and 43

CHW roleCHWs may connect with parents, provide education, navigation, and appropriately code visits (98960–98962) to indicate numerator compliance

ED follow-up timing (FMC / FUA) — measure windows

7-day follow-up windowConnect with member within 7 days of the ED visit (counts as 8 total days in some specs) for follow-up measures

30-day follow-up windowFor some measures, follow-up within 30 days of the ED visit (31 total days per measure spec) qualifies

Documentation requirementWhen documenting CHW services for ED follow-up, include relevant diagnosis (e.g., substance use disorder) and bill with CHW service codes to meet numerator criteria

Clinical thresholds from measures — examples

Asthma Medication Ratio (AMR)Controller-to-total medication ratio >= 0.50

Hemoglobin A1c (HBD)HbA1c control defined as <8.0%; poor control defined as >9.0%

Controlling High Blood Pressure (CBP)Blood pressure control defined as <140/90 mm Hg

Numerator / Denominator — HEDIS notes

Numerator definition (HEDIS)Members who meet compliance criteria based on HEDIS technical specifications for appropriate care, treatment, or service

Denominator definition (HEDIS)Members who qualify for the measure criteria based on HEDIS technical specifications

CHW codes in numerator value setCHW service CPT codes 98960, 98961, 98962 are included in HEDIS numerator value sets to close care gaps

Prior Authorization

Written recommendation required; CHW service codes — requirement for written recommendation from authorized licensed practitioner and referenced procedure codes (98960, 98961, 98962)

CHW services require a written recommendation from a physician or other licensed practitioner authorized to practice within their scope under state law. Recommendations should be submitted to the MCP via the provider portal when the recommending provider has portal access. Providers without portal access may complete the Medi‑Cal Member Recommendation form and provide it to the member and/or CHW; the CHW or Supervising Provider should then upload the recommendation information into the portal (the form file itself is not uploaded). Members may not be enrolled in CHW services and Enhanced Care Management (ECM) concurrently.

Acceptable recommenders include: physicians, physician assistants, nurse practitioners, clinical nurse specialists, podiatrists, nurse midwives, licensed midwives, registered nurses, public health nurses, psychologists, LMFTs, LCSWs, LPCCs, dentists, registered dental hygienists, licensed educational psychologists, licensed vocational nurses, and pharmacists
Submit recommendation via HN provider portal when available; alternative workflow: paper form -> CHW/Supervising Provider uploads info into portal
Concurrent enrollment restriction: CHW services and ECM cannot be provided to the same member at the same time

Billing Rule

Required documentation and coding — include relevant diagnosis and documentation elements when documenting CHW services

CHWs must document each encounter with dates, start/end times or duration, the nature of the service provided, and enough detail to support the time billed. Documentation must be accessible to the Supervising Provider, integrated into the member's medical record, include the CHW's NPI, and be available for encounter data reporting. When documenting services that impact quality measures (HEDIS), include the relevant diagnosis or behavioral health condition and use the appropriate CHW service codes (98960, 98961, 98962) where applicable.

Document: date, time/duration (units = 30 minutes), description of activities, and time justification (e.g., 'Assisted with SNAP application for 30 minutes')
Include CHW's NPI in encounter documentation
Make documentation accessible to the Supervising Provider upon request and integrate into the member's medical record
When supporting HEDIS-related actions, include relevant diagnosis (e.g., depression) and code encounters appropriately (98960/98961/98962)

Documentation Required

Supervising Provider oversight — supervising provider must provide direct or indirect oversight and ensure services comply with requirements

The Supervising Provider is responsible for ensuring CHW services comply with all applicable requirements and must provide direct or indirect oversight. Oversight includes ensuring CHWs are connected to the ordering entity and that services provided meet applicable standards. Supervising Providers must retain evidence of CHW annual training (minimum six hours) and may require or provide additional training as needed.

Supervising Provider need not be the same as the ordering or recommending provider
Supervising Provider need not be physically present during CHW encounters but must ensure compliance
Maintain evidence of CHW annual training (minimum 6 hours) and documentation of oversight activities

Denial Risk

Supervising provider requirement — For Follow-Up After Hospitalization for Mental Illness measure impact, supervising provider must be licensed mental health provider

For quality measures that require mental health follow-up (for example FUH), the supervising provider for CHW services supporting those measures must be a licensed mental health provider.

When CHW activity is used to support Follow-Up After Hospitalization for Mental Illness (FUH) and similar HEDIS measures, supervising provider must be a licensed mental health provider
Document supervision and the member's relevant mental health diagnosis in the encounter

Note

Asthma prevention provider eligibility — licensed and qualified unlicensed providers may provide asthma prevention services per guidance

Asthma prevention services may be delivered by licensed clinicians (physicians, NPs, PAs) and by qualified unlicensed providers such as CHWs, promotores, or community health representatives who meet asthma preventive service provider qualifications per Medi‑Cal guidance.

Unlicensed providers must meet the qualifications described in Medi‑Cal guidance to provide asthma preventive services

Denial Risk

Plan of care and review requirements — failure to have required written plan of care or reviews may trigger denials or modifications

Failure to have a required written plan of care, written recommendation, or required reviews may result in claim denials, requirement for retroactive documentation submission, or modification of services.

Ensure timely submission of written recommendations and plan of care documentation to avoid denials
Keep all encounter documentation, trainings, and supervisory records available for audit or upon request

Primary responsibilitiesEnsure CHW qualifications and training, maintain oversight (direct or indirect), ensure documentation integration into member medical record, and submit claims for CHW services

Oversight expectationsProvide direct or indirect oversight; management tasks may be delegated but final responsibility remains with the Supervising Provider

Health Navigation — definition

DefinitionHealth Navigation: providing information, training, referrals, or support to assist members to access health care, understand the health care delivery system, or engage in their own care

Common tasksOutreach, resource coordination, appointment scheduling assistance, enrollment/maintenance in assistance programs related to health when provided per a plan of care

Role in measuresUsed by CHWs to connect members to services that support HEDIS measures (e.g., appointment facilitation for follow-up, transportation or translation coordination)

Health Education — definition & examples

DefinitionHealth Education: promotion or instruction consistent with established health care standards to improve health or self-management

ExamplesCoaching, goal setting, teaching proper inhaler/spacer use (if CHW trained), providing information on diet/exercise, and administering standardized screens when within scope

Documentation expectationHealth education content must be consistent with recognized standards and documented with dates, time/duration, nature of service, and CHW NPI