Community Health Worker (CHW)

Revised: October 8, 2026

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Noncovered Services

· Billing

· Definitions

· Legal References

Overview

A community health worker (CHW) is a trained health educator and frontline public health worker who is a trusted member of, or has a close understanding of, the community served. CHWs serve as a bridge between Minnesota Health Care Programs (MHCP) members and health care providers by providing outreach, health education, and care coordination to improve access to care in underserved communities.

CHWs work closely with primary care providers to strengthen communication, promote culturally responsive and equitable care, increase health knowledge, support self-management, reduce health disparities and improve health outcomes and quality of care.

Care coordination is covered only when it is part of a diagnosis-related medical intervention and supports a member’s treatment plan. Care coordination is 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 (RN) or non-enrolled PHN working for an enrolled organization. Refer to the following Eligible Providers for who may submit claims as the billing or ordering provider.

Eligible Providers

Requirements to be an eligible provider
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).

Tribal community health representatives may enroll as CHWs as stated under the Community Health Worker Enrollment Criteria and Forms

Providers eligible to bill for CHW services
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.

The following providers are eligible to bill for CHW services:

· 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, but not limited to:

· care coordination

· diabetes prevention

· teaching self-management skills for chronic conditions in conjunction with the health care team

· providing culturally appropriate health education and advocacy

· connecting patients to community resources when related to the diagnosed condition

· pediatric obesity treatment provided by a CHW with the following criteria:

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

· Care coordination activity must support the patient’s education, disease management, or treatment plan ordered by an authorized provider

· 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 or case management 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 format

· Dental CHWs must submit claims on a Dental 837D claim format

· Use the NPI of the hospital, clinic, physician, APRN, public health nursing organization or mental health professional 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 eight patients, use 98962 with the U9 modifier

· S9445 and S9446 individual and group session education codes

· D1206, D1301, D1310, D1320, D1321, and D1330 are billable dental codes

· 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 provide and bill the following procedure codes for members with Medicare and Medicaid for community health integration (CHI) services.

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

· 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. An E&M visit cannot be a low-level (level 1) E&M visit performed by clinical staff. 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.

· Only one eligible provider may bill for CHI services per calendar month, including all subsequent CHI services provided that month. A different eligible provider may bill for CHI services the following month, but only one provider can bill in a single calendar month; and may be any of the eligible providers listed under the eligible provider section. If you choose to switch providers, the new provider needs a new initiating visit to determine medical necessity of the CHI service.

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)