Medicaid: Community Health Worker Enrollment and Billing Instructions

As per the PA Department of Human Services (DHS) and effective April 18, 2026, a Community Health Worker (CHW) may enroll in the Medical Assistance Program to render services to managed care beneficiaries. More information about this update can be found in the Medical Assistance Bulletin (MAB) 08-26-50.

DHS will enroll CHWs certified by the Pennsylvania Certification Board (PCB) under Provider Type 13 (Non-Traditional Provider) with a Provider Specialty Code of 139.

CHW services must be recommended by MA enrolled physicians, physician assistants, certified nurse practitioners, or certified nurse midwives, who are participating with Highmark Wholecare. Both the CHW and supervising provider must be enrolled with DHS at each location where services are rendered.

•  Once enrolled with DHS, a CHW Roster must be completed and submitted to Highmark Wholecare via email at: credentialing_non-delegate_rosters@highmarkwholecare.com. The email subject line should include the following roster naming convention: CHW_Name_State_County_Date submitted (two digit month, two digit day, four digit year).
•  FQHC/RHC providers and those who are delegated for credentialing should submit their CHW information as they currently do, via their rosters or monthly credentialing files. Be sure to note CHW as the provider specialty.
•  Qualifying members must have one or more of the following medical conditions: Asthma, chronic obstructive pulmonary disorder, diabetes or pre-diabetes (excluding gestational diabetes), heart disease, hypercholesterolemia, hypertension, obesity, or the prescribed use of multiple medications.
• Highmark Wholecare will cover three CHW encounters per member per year; additional encounters will not be reimbursed.
• CHW covered services include: Closing care gaps, health education to promote patient health or address barriers to care, health navigation services to support access and connection to community resources, screening for health-related social needs, assistance in enrolling with government services, guidance in health system navigation, and individual support or advocacy services.
•  Submit claims using procedure code and modifier 98960-U2. Reimbursement is set at $25 with a limit of three per member per year.
• Care plan documentation must be in the medical record and indicate referral for CHW services, results of screening/assessment that triggered the referral as well as the recommendations for the covered services. CHW services, including date, time, duration, location, and summary of interventions must also be documented in the medical record.