Policy
Blue Cross Blue Shield of North Dakota (BCBSND) recognizes Community Health Workers and Community Paramedics. Below outlines the guidelines to follow to properly render and bill these services.
To receive payment from BCBSND Medicaid Expansion, the eligible servicing and billing provider National Provider Identifiers (NPI) must be enrolled on the date of service with North Dakota (ND) Medicaid. Servicing providers acting as a locum tenens provider must enroll in ND Medicaid and be listed on the claim form. More details on requirements can be found below.
Basic coverage requirements include:
- The provider must be enrolled in ND Medicaid;
- Services must be medically necessary;
- The member must be eligible on the date of service; and
- If applicable, the service has an approved service authorization.
Community Health Worker (CHW)
CHWs can help engage members with necessary care and increase member health knowledge/literacy and self-sufficiency resulting in healthier members. These services are to engage Medicaid Expansion members with chronic conditions, who are at risk of developing chronic conditions, and who have documented barriers related to access with regular health care. This includes teaching members how to effectively self-manage their chronic condition or delay development of a chronic condition.
Member Eligibility
Providers are responsible for verifying a member’s eligibility before providing services.
CHW preventive services are medically necessary for BCBSND Medicaid Expansion members who meet at least one of the criteria below:
- Has at least one chronic condition (including behavioral health);
- Is at risk for developing at least one chronic condition based on one or more of the following:
- Medical indicators indicating an increasing risk of developing a chronic condition. These indicators may include elevated blood pressure or glucose levels; or
- The presence of known risk factors including tobacco and/or nicotine use, excessive alcohol use, and/or drug misuse.
- Is at risk for developing at least one chronic condition or is unable to self-manage existing chronic conditions based on one or more of the following occurring within the last 12 months:
- One or more visits to an emergency room for the chronic condition;
- One or more hospital inpatient stays for the chronic condition, including stays at a psychiatric facility;
- One or more stays at a residential treatment facility; or
- Two or more missed medical appointments.
- Has a documented barrier that affects the member’s health as indicated through a health-related social needs or social determinants of health screening.
- A documented barrier includes a lack of health literacy to self-navigate the health system/coordinate resources.
Covered CHW services include:
Health System Navigation and Resource Coordination
Understanding and navigating the healthcare system can be complicated and overwhelming for our members. CHWs can offer support in many ways including helping to engage, or re-engage a member in the healthcare system with a focus on preventive care vs. emergency care, ensuring proper follow-up in primary and preventive care, adherence to care plans, attending appointments with the member for support and helping to find other relevant resources such as support groups, food pantries, utilities assistance programs, and any other resources related to social determinants of health barriers the member may have that negatively impacts their health. A CHW may attend an appointment if CHW attendance at that type of appointment is specified in the member’s service plan and there is written consent from the member.
Health Promotion and Coaching
Health promotion and coaching includes providing information that promotes positive contributions to their health. This includes information on tobacco cessation, chronic disease self-management, the reduction of misuse of substances, improvement in nutrition and physical fitness and other health-related social needs.
Health Education and Training
Health education and training is offered by reenforcing education provided by the member’s healthcare team that has been proven to be effective in avoiding or managing illnesses such as immunizations, control of blood pressure and diabetes, safety, and accident prevention.
- Member education services provided by CHWs are to be provided under the guidance of a licensed practitioner.
- Content of patient education must be consistent with established or recognized health or dental standards.
- Diagnosis-related member education
- Reinforcement of health-related education
These services can be individual or group services.
Settings
Services, including initial visits, may be conducted in a health care clinic setting or community-based setting and may include a member’s home. Services are community-based, meaning the bulk of the services should occur in a community versus a clinic setting unless that setting meets the needs of the member.
- CHW services are not allowed in hospitals, intermediate care facilities, nursing homes or basic care facilities, or carceral settings.
- CHW services may be delivered individually or in a group setting.
- CHW services may be provided via telehealth.
CHW Billing Instructions
- Community Health Workers must be certified in the state of North Dakota.
- CHW services are a diagnosis-related medical intervention, not a social service.
- CHWs must be employed by a Medicaid/Medicaid Expansion-enrolled billing provider and the billing provider must have and maintain documentation of CHWs North Dakota certification.
- CHW services may not duplicate other covered BCBSND Medicaid Expansion services.
- If a CHW is qualified to provide another covered service, the CHW must enroll as a provider and bill under the guidelines for that service.
- Example: A CHW provides Non-Emergency Medical Transportation (NEMT) services, the CHW must complete a separate enrollment as a NEMT provider and bill as a NEMT provider.
- CHW services must be rendered under the general supervision of a physician or other licensed practitioner (OLPs).
- Supervision can occur through a signed supervision agreement with an OLP and the agreement must be in writing and maintained by the CHW billing provider.
- Members must be referred for services by a physician, dentist, pharmacist or an OLP and referrals must include:
- CHW services needed
- Duration of CHW services
- Condition(s) and/or barrier(s) the CHW will address
Note: Members requiring more than 12 units of service by a CHW will require a service plan drafted by or reviewed and approved by the supervising practitioner.
CHW services should be billed to BCBSND Medicaid Expansion as follows:
*File claim(s) as applicable according to the service(s) rendered
- Claims format: Professional (837P)
- CPT Code(s): 98960, 98961 and/or 98962 to be billed in 30-minute increments
- Limit: No more than 4 units (2 hours) of any combination of 98960, 98961, and/or 98962 are billable on a single date of service. This is a hard limit.
- Provider Information: CHWs are employed by a health care provider and must bill using their National Provider Identifier (NPI) and the supervising provider’s NPI.
- Taxonomy: 172V00000X
CHW Documentation Requirements
Providers must keep legible medical and financial records that fully justify and disclose the extent of services provided and billed. Records must be retained for at least seven (7) years after the last date the claim was paid or denied. Providers must follow the documentation requirements as outlined in the BCBSND Medicaid Expansion provider manual.
CHWs must maintain documentation of all services delivered, regardless of the number of units delivered and billed.
Service Plan
A service plan drafted by or reviewed and approved by the supervising practitioner is required when the member requires continued CHW services after 12 units of service. CHWs may participate in care teams developing service plans.
- Service plans must be reviewed every six (6) months to determine if progress is being made and whether CHW services continue to be medically necessary. Service plan reviews and any resulting changes must be documented.
- Plans, when required, must be finalized prior to additional CHW services being rendered.
- The service plan must state:
- How the members need for CHW services relates directly to one or more eligibility criteria.
- The barrier or reason for the referral
- For example, if a member has missed two or more appointments related to their diabetes; and
- The duration of time CHW services is needed to accomplish the service plan goals.
Note: For services not ordered by a member’s primary care provider, the CHW must forward the order, service plan, and related documentation to the member’s primary care provider for their awareness.
Health-Related Social Need Screening Instruments
Documentation of a barrier that affects the individual’s health must include the results of an accepted health-related social needs or social determinants of health screening instrument.
Community Paramedic
Community paramedic services are a covered service rendered by a community paramedic, community advanced emergency technician or community emergency medical technician under the supervision of a physician, physician assistant or advanced practice registered nurse.
Member Eligibility
Providers are responsible for verifying a member’s eligibility before providing services.
Community Paramedic Billing Instructions
- Community Paramedic services can be provided by the following enrolled providers as allowed by their scope of their licensure:
- Community emergency medical technician
- Community advanced emergency medical technician
- Community Paramedic
- Community Paramedicine services may not duplicate other covered BCBSND Medicaid Expansion services.
- If a community paramedicine provider is qualified to provide another covered service, the community paramedicine provider must be enrolled under that provider type and bill under the guidelines for that service.
- Example: A community paramedicine provider provides ambulance services; the community paramedic must complete a separate enrollment as an ambulance provider and bill as an ambulance provider.
- Community Paramedic services must be referred by a physician, physician assistant or advanced practice registered nurse and delivered to a Medicaid Expansion enrolled member to receive reimbursement.
- All covered services must be delivered by an eligible provider who is employed by an ambulance service or hospital.
Covered Services
- Health assessment;
- Chronic disease monitoring and education;
- Vaccine administration;
- Laboratory specimen collection;
- Follow-up care;
- Comprehensive health and safety assessment;
- Wound management;
- Assess and report compliance with established care plan;
- Medication management; and
- Other interventions within the scope of practice for each licensure level as approved by a supervising physician, physician assistant, or advanced practice registered nurse.
Non-Covered Services
Noncovered Community Paramedic Services include:
- Travel time
- Mileage
- If the member requires ambulance transport, services will be billed in accordance with the Ambulance Services policy
- Personal care services
- Services related to hospital-acquired conditions or treatments
Community Paramedic services should be billed to BCBSND Medicaid Expansion as follows:
*File claim(s) as applicable according to the service(s) rendered
- Claims format: Professional (837P)
- CPT Code: 99600
- Place of Service: must be the member’s home or place of residence.
- Home 12;
- Homeless Shelter 04;
- Custodial Care Facility 33;
- Outreach Site or Street 27; or
- Residential Treatment Center 55
- Bill the applicable medically necessary units
- Provider Information: Community Paramedics are employed by a health care provider and must bill using their National Provider Identifier (NPI) and the supervising provider’s NPI.
- Taxonomy: 146E00000X
Community Paramedic Documentation Requirements:
Providers must keep legible medical and financial records that fully justify and disclose the extent of services provided and billed to ND Medicaid. Records must be retained for at least seven (7) years after the last date the claim was paid or denied. Providers must follow the documentation requirements as outlined in the BCBSND Medicaid Expansion provider manual, including:
- Location of service delivery
- Services delivered
- Time spent with the member
- Referral-clearly indicate the referring provider information
Reimbursement Methodology and Claim Instructions
Refer to the Medicaid Expansion provider manual for information on claim timely filing, third party liability, and additional claim filing details.
Limitations and Exclusions
While reimbursement is considered, payment determination is subject, but not limited to:
- Group or Individual benefit
- Provider Enrollment
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits and medical necessity.
- Mandated or legislative required criteria will always supersede.
Definitiions
Advanced Emergency Medical Technician – an individual certified by the national registry as an advanced emergency medical technician. An advanced emergency medical technician is eligible for licensure as an advanced emergency medical technician upon completion of a license application and approval by the department.
Chronic condition – means a condition that lasts twelve months or longer and requires ongoing medical attention and/or limits a member’s activities of daily living. At risk for a chronic condition may include the following criteria: obesity, prediabetes, tobacco or nicotine use.
Documented barriers – may include transportation needs, cultural or language barriers, and/or lack of a telephone, financial constraints, social isolation, access to healthy food, housing, or transportation.
Emergency Medical Technician – an individual certified by the national registry as an emergency medical technician. An emergency medical technician is eligible for licensure as an emergency medical technician upon completion of a license application and approval by the department.
General supervision – means a service is furnished under a physician or OLP’s overall direction and control, but the physician or OLP's presence is not required during the performance of the service.
Health-related social needs – means the resulting effects of social determinants of health that negatively impact a member’s circumstances and are in the purview of health care providers to identify and help address. HRSNs can be linked to poorer health outcomes, greater use of emergency departments and hospitals, and higher health care costs.
Paramedic – a person that has fulfilled the training, testing, certification, and licensure process for paramedic as required in chapter 33-36-01.
Preventive Services – means services to prevent disease, disability, or other health condition or the progression of a disease, disability, or health condition.
Social Determinants of Health – Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks (Healthy People 2030). Social determinants of health can influence the diagnosis and treatment of health conditions.
Telehealth – an umbrella term which includes digital health and synchronous two-way real-time interactive audio/visual services. It does not include store and forward services.
Cross Reference
