Pennsylvania Medicaid: Support patients with new CHW services benefit

By April 18, 2026 (CHW enrollment begins): (1) Billing team must add procedure codes 98960–U2 (30-minute increments, $25/unit) and T1015 to billing system for PA Medicaid claims. (2) Configure system to limit billing to 3 units maximum per member per calendar year. (3) For FQHCs/RHCs: Set billing rules to use 98960–U2 when CHW is only service provided, or T1015 when combined with other services (applies to plan-negotiated rates outside PPS). (4) Providers and clinical staff must update referral process to require documented physician/PA/CRNP/CNM order and care plan inclusion before CHW services are rendered. (5) Implement documentation checklist requiring: date, time, duration, location, modality, appointment assistance, patient education, screening results, resource navigation, and medication adherence support. (6) Train front desk and clinical staff on CHW service scope limitations (exclude case management, transportation, housing, childcare, medication delivery, interpreter services, exercise programs, duplicate/missed visits, and non-Medicaid member services). Failure to comply will result in claim denials and potential billing violations.