MedicaidBilling CodesHigh impact
Community Health Worker (CHW) billing update
Geisinger Health Plan·PA · Family Medicine, Internal Medicine, Pediatrics +3 more·Claims
Effective date
Jan 1, 2026
We identified it
Jul 29, 2026
Summary
Effective January 1, 2026, GHP Family now allows certified Community Health Workers (CHWs) to bill for services using procedure code G0019 at $27.98 per unit, limited to 3 visits per member per year. CHWs must obtain Pennsylvania certification, PROMISe ID enrollment, and DHS enrollment at each service location. Billing team must implement new code workflows, documentation requirements, and visit limits to ensure compliance.
Action Required
By January 1, 2026: (1) Billing team must configure billing system to accept procedure code G0019 at flat rate of $27.98 per unit. (2) Implement automated visit limit edits to block billing beyond 3 visits per member per year and flag denials as provider responsibility. (3) Update claim submission templates to require CHW certification verification and PROMISe ID documentation before processing. (4) Clinical staff must verify that CHW services are ordered by eligible practitioners (physician, LCSW, CNM, etc.) and condition is on approved list (asthma, COPD, diabetes, heart disease, hypertension, obesity, etc.). (5) EMR/documentation team must add mandatory fields to CHW visit records: date, time, duration, location, and intervention summary. (6) Confirm CHW and supervising provider DHS enrollment at each location where services are rendered. Verify PROMISe ID is linked to billing location and supervising provider. (7) Exclude non-covered services from billing: transportation, housing assistance, case management, childcare, and others in Exhibit B(5b) of 2026 HealthChoices contract. Failure to implement visit limits will result in claim denials for visits 4+ being provider responsibility. Contact GHP Provider Services (800-876-5357) for questions.