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Community Health Worker (CHW)

Revised: 04-26-2016

  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Non-covered Services
  • Billing
  • Definitions
  • Legal References
  • Overview

    A community health worker (CHW) is a trained health educator who works with MHCP recipients who may have difficulty understanding providers due to cultural or language barriers. CHWs extend the reach of providers into underserved communities, reducing health disparities, enhancing provider communication, and improving 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 providing 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) or mental health professional.

    Eligible Providers

    Providers must have a valid certificate from the Minnesota State Colleges and Universities (MnSCU) demonstrating that the applicant has completed an approved community health worker curriculum.

    Enrollment Criteria

    MHCP requires CHW enrollment so they are represented on a claim as the provider who provided the services.

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

  • MHCP Provider Agreement (DHS-4138) (PDF)
  • MHCP Enrollment Application (DHS-4016) (PDF)
  • MHCP Applicant Assurance Statement (DHS-5308) (PDF)
  • Attach a copy of your MnSCU CHW certification to the application form.

    Submit all signed and completed forms to MHCP at one of the following:

    FAX to (preferred): 651-431-7462

    Mail to:
    DHS-MHCP Provider Enrollment
    PO Box 64987
    St. Paul, MN 55164-0987

    Currently enrolled CHWs must inform DHS of their affiliation with dentists, ARPNs, certified PHNs or mental health professionals by submitting a signed and completed Individual Practitioner MHCP Provider Information Change Form (DHS-3535) (PDF).

    MHCP Provider Enrollment will notify applicants of the status of their application within 30 days of receiving the signed and completed application, agreement, and applicant assurance statement.

    Enrolled CHWs are considered a non-pay-to provider. An eligible MHCP enrolled billing provider must bill for services for the CHW to receive payment.

    Eligible Billing Providers

  • • Advance practice registered nurse (APRN)
  • • Clinic
  • • Community health clinic
  • • 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
  • • Rural health clinics (RHC)
  • • Tribal health facility
  • Provider Type Home Page Links
    Review related Web pages for the latest news and additions, forms, and quick links

  • Eligible Recipients

    MHCP recipients of the Medical Assistance (MA) and MinnesotaCare programs are eligible to receive education services provided by a CHW.

    MHCP recipients 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 or APRN, certified public health nurse, dentist or mental health professional.
  • • A, physician, APRN, dentist, certified public health nurse or mental health professional must order the patient education service(s) and must order that they be provided by a CHW.
  • • The service involves teaching the patient how to self-manage their health or oral health effectively in conjunction with the health care team.
  • • The service is provided face-to-face with the recipient (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 recipient’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 (at least monthly) assessment of the recipient’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

  • Bill MHCP electronically using 837P:
  • • Use hospitals, clinics, physicians, APRN’s, public health nursing organization’s or mental health professional’s National Provider Identifier (NPI) as billing provider
  • • Use the following procedure codes:
  • • 98960 Self-management education & training, face-to-face, 1 patient
  • • 98961 Self-management education & training, face-to-face, 2–4 patients
  • • 98962 Self-management education & training, face-to-face, 5–8 patients
  • • Bill in 30-minute units: limit 4 units per 24 hours; no more than 24 units per calendar month per recipient
  • • Bill separate lines for each day service is provided (only one calendar month of service per claim)
  • • Enter appropriate diagnosis
  • • Use CHW non-pay Unique Minnesota Provider Identifier (UMPI) number as rendering provider
  • The billing provider must meet the same documentation requirements listed above. The documentation must support the number of units billed.

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

    MCO

    Providers must bill the enrollee’s appropriate 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 (IHS) funded, tribally contracted or granted and directed program of training.

    Community health worker (CHW): A health worker who is a trusted member of 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, subd. 49 (Community health worker)
    Minnesota Statutes 245.462
    , subd. 18 (Mental health professional)
    Minnesota Statutes 245.4871
    , subd. 27 (Mental health professional)

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    Updated: 4/26/16 9:40 AM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 4/26/16 9:40 AM