The following FAQs provide additional guidance and clarification to Medi-Cal providers regarding CHW services.

Billing 

Billing Overview

1.   How should a CHW document their services for billing?

CHWs are required to document the dates and time/duration of services provided to Medi-Cal members. Documentation should also reflect information on the nature of the service provided and support the length of time spent with the member that day. For example, documentation might state, “Discussed the member’s challenges accessing healthy food and options to improve the situation for 15 minutes. Assisted with SNAP application for 30 minutes. Referred Medi-Cal member to XYZ food pantry.”

In addition, For Current Procedural Terminology (CPT) codes 98960, 98961 and 98962, supervising providers must document a clinically appropriate International Classification of Diseases, 10^th Revision, Clinical Modification (ICD-10-CM) diagnosis code(s) in the Medi-Cal member’s medical record. Similarly, for HCPCS codes G0019 and G0022, supervising providers must list one of the allowable ICD-10-CM diagnosis code(s), as designated by the Department of Health Care Services (DHCS) and outlined in the Community Health Worker (CHW) Preventive Services section of the Medi-Cal Provider Manual.

All documentation shall be accessible to the supervising provider to support claims submitted for reimbursement.  All documentation shall also be accessible to DHCS upon request or made available in the event of a state and/or federal audit.

2.   What are the billing codes for CHW services?

Individual Medi-Cal Member Billing

Supervising providers may use the following Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes when submitting claims for covered CHW services provided to an individual Medi-Cal member, consistent with all of the following requirements outlined in the Community Health Worker (CHW) Preventive Services section of the Medi-Cal Provider Manual:

• CPT code 98960 – This code may be used for any covered CHW services rendered directly to a Medi-Cal member and may also include caregiver(s)/family.
• HCPCS code G0019 – This code may be used for any covered CHW services following an initiating visit with a licensed provider within the preceding six (6) months in which one or more unmet Social Determinants of Health (SDOH) needs were identified that significantly impact or limit a licensed provider’s ability to effectively diagnose and treat the Medi-Cal member.
• HCPCS code G0022 – This code may be used, in conjunction with HCPCS code G0019 when additional services are needed within a calendar month (30-minute increments).

Additional information on special billing requirements and other policy limitations may be found in the Community Health Worker (CHW) Preventive Services section of the Medi-Cal Provider Manual.

Group Medi-Cal Member Billing

Supervising providers may use the following CPT codes when submitting claims for covered CHW services provided to two or more Medi-Cal members in a group setting, consistent with all of the following requirements outlined in the Community Health Worker (CHW) Preventive Services section of the Medi-Cal Provider Manual:

• CPT code 98961 – This code may be used for any covered CHW services rendered to a group of two (2) to four (4) Medi-Cal members and may also include caregiver(s)/family.
• CPT code 98962 – This code may be used for any covered CHW services rendered directly to a group of five (5) to eight (8) Medi-Cal members and may also include caregiver(s)/family.

3. Are ICD-10-CM diagnosis codes required for billing CHW services?

Yes, as noted in the response to #1 above, an ICD-10-CM diagnosis code is always required, as follows:

• For CPT codes 98960, 98961, and 98962, providers must list a clinically appropriate ICD-10 diagnosis code(s) on the claim form in accordance with their scope of practice.
• For HCPCS codes G0019 and G0022, providers must list one of the allowable ICD-10-CM diagnosis code(s) on the claim form, as outlined in the Community Health Worker (CHW) Preventive Services section of the Medi-Cal Provider Manual, in accordance with their scope of practice. These include ICD-10-CM diagnosis codes Z55-60 and Z62-65.

4.   Is a modifier required when billing for CHW services?

Yes, all supervising providers must use modifier U2 with CPT and HCPCS codes to denote services rendered by CHWs. Appropriate modifier use allows DHCS to accurately track and monitor CHW utilization. Claims submitted without the required modifier may be denied.

Time, Units, and Frequency

5. Do time-based CPT codes (30-minute increments) have any special requirements and can services rendered at less than 30-minute frequency be billed?

DHCS follows the most recent version of the American Medical Association’s CPT Professional Codebook, which follow a “midpoint” plus one minute rule for time-based CPT codes (for example, 30 minutes). Accordingly, CHW services rendered must be for at least 16-minutes (i.e., “midpoint” of 15 minutes plus one minute) to bill for one unit (30 minutes).  

Providers cannot combine multiple short segments across the day (or multiple days) to meet this threshold as each unit represents a single, uninterrupted session/visit. However, CHWs can perform multiple covered CHW services during a session to satisfy the 16-minute requirement.

For providers that have multiple sessions/visits in one day, each session/visit must independently meet the minimum threshold (greater than or equal to 16 minutes) and be documented separately. This is also true for each unit (30-minute increment) being billed.

Example 1: CHW assists member with health navigation. Spends 12 minutes assisting member with completing forms and gathering verifications for a Medi-Cal eligibility redetermination. Once completed, CHW spends 8 minutes assisting member with also initially applying for CalFresh. Total time spent is 20 minutes during the one session, which meets requirement to bill for one unit (30 minutes).

Example 2: CHW provides health education and health navigation. Spends 30 minutes providing guidance on the importance of regular exercise as well as healthy eating and maintaining a balanced diet, including making recommendations for how the member can make small adjustments to their diet to reduce fat and increase protein intake. Once completed, CHW spends 17 minutes assisting a Medi-Cal member with initially enrolling in CalFRESH, including conducting some quick internet research on eligibility requirements and collecting necessary documentation. Total time spent is 47 minutes during one session, which satisfies the requirement to bill for two units (60 minutes).

6. Do time-based HCPCS codes (30-minute increments) have any special requirements and can services rendered at less than 30-minute frequency be billed?

CHW services using G0019 and G0022 may be cumulative over the calendar month.  For HCPCS code G0019 (60 minutes per unit), supervising providers must document at least 31 minutes to bill one unit; documentation should reflect actual time spent, including start/end times or total duration.  For HCPCS code G0022 (30 minutes per unit), providers must document at least 16 minutes to bill one unit; documentation should reflect actual time spent, including start/end times or total duration. Providers may combine multiple sessions over a calendar month.  Each session should include its own start/end times, topics covered, and member engagement details. HCPCS code G0022 must be billed in conjunction with HCPCS code G0019. HCPCS code G0022 may be stacked (added together) if total CHW time delivering services exceeds 90 minutes in a calendar month.

7.   What is the maximum frequency/limit a CHW can bill for services per Medi-Cal member, per day?

All CHW billing codes have frequency and other policy limitations, including:

• For CPT codes 98960, 98961, and 98962, supervising providers may bill up to two hours (four 30-minute units) daily per Medi-Cal member with any CHW.
• For HCPCS codes G0019, supervising providers may bill up to 60 minutes (one unit) daily per Medi-Cal member with any CHW. This code cannot be billed in the same calendar month as CPT code 98960 by the same supervising provider.
• For HCPCS code G0022, supervising providers may bill up to two hours (four 30-minute units) monthly per Medi-Cal member with any CHW. This code must always be billed in conjunction with HCPCS code G0019.

For any frequency or other policy limitation, additional services may be provided with approved treatment authorization request (TAR) establishing medical necessity. A TAR may be submitted after services are provided. Please note that the maximum daily limit does not apply to services rendered in an emergency department. 

8.   Can a CHW provide group education and training to more than eight Medi-Cal members at once?

Yes, CHWs may render covered services in a group setting to more than eight Medi-Cal members; however, the maximum number of Medi-Cal members for which CHW services can be billed during one session is eight. The intent behind the policy is to ensure group sizes remain small enough to allow CHWs to effectively render services to the group and members to meaningfully participate.

Example:  CHW provides group education for eight members on Tuesday and a separate 30-minute session of group education for ten members on Wednesday. The supervising provider can bill using CPT code 98962 for eight members for Tuesday and for eight members on Wednesday.

Claim Submission

9.   Do CHWs submit claims for billing?

No. Claims for CHW services may only be submitted by the CHW’s supervising provider, who is enrolled in Medi-Cal, to either the Medi-Cal member’s managed care plan or directly to DHCS if the member has fee-for-service Medi-Cal.

10. Do CHWs need to obtain a National Provider Identifier (NPI) in order to provide services to Medi-Cal members?

No. CHWs do not need to obtain an NPI at this time. If this changes, DHCS will inform supervising providers and CHWs, prior to implementing this requirement and provide technical assistance if/as needed.

CPT vs HCPCS Requirements

11. What are the requirements for billing CHW services using HCPCS codes G0019 and G0022?

• A licensed provider must conduct an initiating visit within the preceding six months.
• The provider must identify one or more unmet SDOH needs that limit their ability to diagnose or treat the member.
• A treatment plan must be developed and approved by a licensed provider and include an applicable ICD-10-CM diagnosis code(s) as outlined in Medi-Cal policy. It must identify one or more unmet SDOH needs that significantly limit the ability of the provider of the initiating visit to diagnose or treat problems. It should include general goals and steps to achieve those goals.
• CHW services must be provided based on the treatment plan.

NOTE: These requirements do not apply to CPT codes 98960, 98961, or 98962.

12. Is an initiating visit required before CHW services can be billed?

For CPT codes, an initiating visit is not required when billing CPT codes 98960, 98961, or 98962. However, an initiating visit is always required before CHW services can be billed under HCPCS codes G0019 and G0022. The initiating visit is part of the HCPCS code description and DHCS does not have the authority to modify the requirements of the HCPCS codes to eliminate the initiating visit without seeking approval from the Centers for Medicare and Medicaid Services (CMS).

13. What type of visits would be considered an initiating visit?

• The initiating visit must be billed with one of the following CPT (Evaluation and Management (E&M) codes:
  • Office or other outpatient services: CPT codes 99203-99205 and 99213-99215
  • Home or residence services: CPT codes 99342, 99344-99345, and 99348-993450
  • Preventive medicine services: CPT codes 99381-99387 and 99391-99396
• Example: A Medi-Cal member has an office visit with their physician billed with CPT 99213. During the visit, the Medi-Cal member’s primary care physician identifies two unmet SDOH needs, including food insecurity and transportation barriers, and recommends CHW services. Since CPT 99213 is a qualifying CPT (E&M) code, it satisfies the initiating visit requirement for subsequently billing HCPCS codes G0019 and G0022.

14. Can the recommending providers for CPT codes 98960, 98961, and 98962 conduct the initiating visit when billing HCPCS codes?

While DHCS provides flexibilities in terms of the providers who can recommend CHW services billed by CPT codes 98960, 98961, and 98962, only providers who may bill with the CPT (E&M) codes identified in Medi-Cal policy may conduct the initiating visit when billing HCPCS codes. The flexibilities that DHCS allows for the recommending provider, including out-of-network providers for CPT codes, does not align with the requirement for an initiating visit billed with HCPCS code G0019 prior to billing HCPCS code G0022. Requiring a CPT (E&M) code for the initiating visit is consistent with CMS’ policy guidance and it allows DHCS to confirm that an initiating visit occurred prior to HCPCS code G0019 being billed for a Medi-Cal member.

15. Can the time that CHWs spend performing reasonable and necessary activities as outlined in the Medi-Cal Provider Manual, on behalf of a Medi-Cal member count toward the total time billed for the month under HCPCS codes G0019 and G0022?

Yes, DHCS has adopted the same code description as Medicare that allows for reimbursement for reasonable and necessary services.

16. Can the standing recommendation for CHW services be used for HCPCS codes G0019 and G0022?

No, the standing recommendation cannot be used for HCPCS codes G0019 and G0022 because an initiating visit and development of a treatment plan are required prior to billing HCPCS codes G0019 and G0022. The standing recommendation may only be used when billing the CPT codes.

17. Can the HCPCS codes G0019 and G0022 be used for Justice Involved (JI) Services?

No. Only CPT codes 98960, 98961, and 98962 may be used for CHW services provided for JI services.

18. Does DHCS plan to publish standardized Medi-Cal reimbursement rates for HCPCS codes G0019 and G0022?

Currently there is not an established Medi-Cal fee-for-service (FFS) reimbursement rate on file (i.e., on the Medi-Cal Rates page). As a result, it is priced at $0.00 in DHCS’ Medi-Cal FFS billing system and therefore reimbursed “by report”. This means that providers who submit a Medi-Cal FFS claim for HCPCS codes G0019 and G0022 will need to also submit cost documentation so it can be manually priced by the DHCS’ Fiscal Intermediary. For more information on “by report” billing, please refer to the CMS-1500 Special Billing Instructions section of the Medi-Cal Provider Manual. DHCS is actively collaborating with CMS to secure approval for rates associated with HCPCS codes G0019 and G0022. Once CMS grants approval, DHCS will update the Medi-Cal Rates page.

Telehealth

19.   Can CHW services billed with either the CPT or HCPCS codes be provided by telehealth modalities?       

Refer to the Telehealth Modalities section of the Medi-Cal Provider Manual.

Special Billing Scenarios

20.   How do CHW services interplay with Enhanced Care Management services provided by Medi-Cal managed care plans under CalAIM?

Please refer to Question #10 on the CHW FAQ for General Information.

21. If a CHW assists an individual with enrollment into Medi-Cal and the individual has presumptive eligibility (PE) granted, can the supervising CHW bill for these services?

During the PE period the member is enrolled in Medi-Cal Fee-For-Service (FFS) and regardless of whether a member applies for or is determined eligible and enrolled in full-scope Medi-Cal after the PE period, any eligible CHW services rendered during the PE period may be billed to Medi-Cal FFS by the supervising provider as outlined in Hospital Presumptive Eligibility Program | DHCS. Dates of service (DOS) must be during the PE period or after enrollment into full-scope Medi-Cal to receive reimbursement for these services.  As the member is enrolled in FFS during the PE period, the supervising provider should not bill a Medi-Cal Managed Care Plan (MCP) during this period.

Example: Individual who was enrolled in Hospital Presumptive Eligibility asks a CHW to help them apply for Medi-Cal, and the HPE period ends on 6/27/2026. The CHW helps the individual fill out the forms, gather their verifications and supporting documentation on 6/29/2026. The individual submits the information on 6/29/2026.  The county later denies the Medi-Cal application for as the member is over the income threshold. The services rendered by the CHW on 6/29/26 can be billed to Medi-Cal as the individual had PE during the time the services were rendered

Resources

22. Whom can I contact if I have questions?

Supervising providers and CHWs may direct questions as follows:

• For questions about Fee-For-Service (FFS) billing, contact DHCS’ Telephone Service Center at (800) 541-5555.
• For questions about MCP billing, contact the MCP directly. To locate a member’s MCP, visit the Medi-Cal Managed Care Health Plan Directory | DHCS.
• For Medi-Cal policy and benefits-related questions, contact DHCS’ Benefits Division at CHWBenefit@dhcs.ca.gov.