FREQUENTLY ASKED QUESTIONS (FAQS) FOR MEDI-CAL COMMUNITY HEALTH WORKER (CHW) SERVICES- Billing
The following FAQs provide additional guidance and clarification to Medi-Cal members and providers regarding CHW services.
Billing
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 a brief description of services rendered, which aligns with visit duration. For example, documentation might state, “Discussed the patient’s challenges accessing healthy food and options to improve the situation for 15 minutes. Assisted with SNAP application for 30 minutes. Referred patient to XYZ food pantry.” Documentation shall be accessible to the supervising provider upon request of the supervising provider and should be appropriately maintained by the CHW in the event of an audit.
2. What are the billing codes for CHW services?
The following billing codes (i.e., Current Procedural Terminology (CPT) codes) may be used for all covered CHW services by the supervising provider when submitting claims:
- CPT code 98960 self-management education and training, face-to-face, 30 minutes, 1 patient
- CPT code 98961 self-management education and training, face-to-face, 30 minutes, 2–4 patients
- CPT code, 98962 self-management education and training, face-to-face, 30 minutes, 5–8 patients
Additionally, DHCS has added Healthcare Common Procedure Coding System (HCPCS) codes G0019 and G0022 as benefits effective April 1, 2024. These HCPCS codes are billable for individual Medi-Cal members and is used in lieu of CPT code 98960 in certain circumstances in which CHWs need to more acutely address issues related to Social Determinants of Health (SDOH), which include factors such as housing, education, and income that affect a person’s health, and are envisioned to help Medi-Cal members better navigate the health care system and access necessary resources. For more information regarding HCPCS codes G0019 and G0022, please see the HCPCS codes FAQ.
For more guidance regarding billing codes, please visit the billing codes section of the Provider Manual: Community Health Worker (CHW) Preventive Services.
3. 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.
4. What is the maximum frequency/limit a CHW can bill for services per Medi-Cal member, per day?
The maximum frequency is four units (two hours) daily per Medi-Cal member, any provider. Additional units per day may be provided with approved prior authorization for medical necessity. Prior authorization may be submitted after the service was provided. Please note that the maximum daily limit does not apply to services rendered in an ED.
5. Does the CHW submit claims for billing?
No. Since CHWs do not enroll with DHCS, claims for their services must be submitted by an enrolled supervising provider to either the Medi-Cal member’s managed care plan if the Medi-Cal member is in managed care or to DHCS if the member has fee-for-service Medi-Cal.
6. Does a CHW need to obtain a National Provider Identifier (NPI) in order to bill for services provided to Medi-Cal members?
No. CHWs do not need to obtain an NPI at this time. If this changes, DHCS will inform supervisor providers and CHWs prior to implementing this requirement and provide technical assistance if/as needed.
