Standalone Community Health Worker (CHW) services can be billed to an appropriate Medi-Cal health plan for up to 12 units (6 hours) without prior authorization from a provider. This means CHWs can provide up to six hours of services before additional approval from the health plan is required. If more than 12 billable units are needed, a Request for Authorization of Additional Units form must be submitted to the health plan. This request must include a Plan of Care signed by a licensed provider to show that ongoing CHW support remains necessary.
As a Pear Suite subcontractor, Pear Suite will provide the required licensed provider signature and manage the submission process on your behalf.
The Request for Authorization of Additional Units form is required when a member needs more than the initial 12 units of Community Health Worker (CHW) services. This form confirms that continued CHW services are appropriate, coordinated, and consistent with Medi-Cal’s CHW benefit. A clear and well-written Plan of Care strengthens the likelihood of approval by the health plan and helps ensure all services meet the conditions described in DHCS APL 24-006.
Important: It’s your responsibility to ensure the Plan of Care is completed accurately and with enough detail before uploading it to the member’s Pear Suite profile so Pear Suite can review and submit it to the health plan. Supervising providers and CHWs may direct questions as follows:
For questions about Fee-For-Service (FFS) billing, contact DHCS' Telephone Service Center at 1-800-541-5555.
For Medi-Cal Policy and benefits-related questions, contact DHCS' Benefits Division at CHWBenefit@dhcs.ca.gov
In the member's profile click +Create Review Request
Select the option for Request Additional CHW Billing Units 4. Under Supporting Files, select Attach Existing File if you've already loaded the completed request form to the member's Files section. Otherwise select Upload New File to load the completed request form from your computer.
Under Additional Units Requested, enter the number of billable units you indicated on the request form. Click Save & Submit for Review.
The status of your request will appear as Sent while it is awaiting approval.
Once approved or denied, the status will adjust accordingly. You can click into the request to see the details and any notes added by the reviewer.
Guidance for Completing the Plan of Care
The information below provides guidance for completing each section of the Plan of Care. These examples are designed to help you understand how to meet documentation requirements outlined in DHCS APL 24-006 and ensure requests for additional CHW units are complete and accurate.
List of health care professionals providing treatment for the condition or barrier the member is affected by.
List the licensed or clinical providers who are treating the member for the condition(s) or barrier(s). Include any professionals who are actively providing treatment related to the member’s health needs.
Notice: The examples provided are for reference only and are not intended to be used verbatim in a member’s Plan of Care. All submitted information must accurately reflect the individual member’s condition, needs, and level of care.
Examples:
Example 1:
The member is currently being treated by a primary care provider and a registered dietitian for diabetes management.
Example 2:
The member receives ongoing care from a primary care provider and a pulmonologist for asthma and related respiratory concerns.
Example 3:
The member receives treatment from a behavioral health clinician and a primary care provider for depression, anxiety, and related health needs.
List in detail the condition or barrier that the relevant service is being ordered for.
Describe the member’s health condition or health-related social need that the CHW will help address. Be specific about what is limiting the member’s ability to improve their health or access care. You can reference recent indicators such as screenings, emergency department visits, missed appointments, difficulty following care plans, or challenges with accessing resources.
Notice: The examples provided are for reference only and are not intended to be used verbatim in a member’s Plan of Care. All submitted information must accurately reflect the individual member’s condition, needs, and level of care.
Examples:
Example 1:
The member has uncontrolled diabetes with repeated difficulty accessing healthy food, managing medications, and understanding dietary recommendations. The member reports inconsistent blood sugar monitoring and has missed recent follow-up appointments.
Example 2:
The member is experiencing worsening asthma symptoms due to unstable housing and exposure to environmental triggers. The member has visited the emergency department twice in the past six months and has not been able to complete recommended follow-up care without CHW intervention.
Example 3:
The member has ongoing depression and anxiety that affect their ability to attend appointments, manage daily tasks, and follow through with behavioral health treatment recommendations. The member reports trouble staying organized and often feels overwhelmed by care instructions.
List the written objectives that specifically address the condition or barrier.
Describe the goals that the member needs to reach in order to address the condition or barrier. Goals should be specific, focused, and closely tied to the issue described in the previous section.
Notice: The examples provided are for reference only and are not intended to be used verbatim in a member’s Plan of Care. All submitted information must accurately reflect the individual member’s condition, needs, and level of care.
Examples:
Example #1: Member will increase access to healthy food options and learn how to manage medications consistently.
The objective is for the member to improve control of their diabetes by gaining consistent access to healthy food, taking medications as prescribed, and understanding how to follow their care instructions. The member will work toward building daily routines that support blood sugar management and reducing avoidable complications related to inconsistent nutrition and medication use.
Example #2: Member will complete recommended follow-up visits and reduce avoidable emergency department use.
The objective is for the member to complete all recommended follow-up medical visits and improve self management skills in order to reduce avoidable emergency department use. The member will work toward understanding care recommendations, preparing for upcoming appointments, and addressing barriers that have led to delayed or missed follow-up in the past.
Example #3: Member will improve appointment attendance and follow the behavioral health care plan.
The objective is for the member to attend scheduled behavioral health and medical appointments consistently and follow the treatment plan developed with their provider. The member will work toward strengthening coping skills, improving organization around appointments and medications, and addressing barriers such as transportation or difficulty managing daily tasks.
List the specific services required for meeting the written objectives.
List the CHW services that will support the member in reaching the written objectives. These should directly connect to the goals and address the specific needs identified in the Plan of Care.
Notice: The examples provided are for reference only and are not intended to be used verbatim in a member’s Plan of Care. All submitted information must accurately reflect the individual member’s condition, needs, and level of care.
Examples:
Example 1:
The CHW will help the member understand medication instructions, apply for food resources, prepare for medical visits, and develop routines that support diabetes self management.
Example 2:
The CHW will support the member with scheduling and preparing for follow up appointments, coordinating transportation, reviewing care recommendations, and reducing barriers that lead to repeated emergency department use.
Example 3:
The CHW will assist the member with appointment reminders, care plan organization, support during behavioral health treatment tasks, and coaching on coping strategies that improve engagement with care.
Include the frequency and duration of CHW services, not to exceed the provider’s order, to be provided to meet the plan’s objectives.
Explain how often the CHW will meet with the member and how long each visit will last. Make sure the frequency and duration are appropriate for the member’s needs and align with the licensed provider’s order.
Notice: The examples provided are for reference only and are not intended to be used verbatim in a member’s Plan of Care. All submitted information must accurately reflect the individual member’s condition, needs, and level of care.
Examples:
Example 1:
The CHW will meet with the member once per week for thirty minutes over a three month period to support diabetes self management and follow up care.
Example 2:
The CHW will meet with the member two times per month for sixty minutes to support completion of follow up visits and reduce avoidable emergency care over a ninety day period.
Example 3:
The CHW will meet with the member one time per week for thirty minutes over the next three months to support behavioral health engagement and improve appointment attendance.
Unit Calculation Guide: • Weekly 60-minute visits for 12 weeks = 24 units • Twice-monthly 90-minute visits for 3 months = 18 units • Mix of visits: Month 1 (4×60 min = 8 units), Month 2 (2×30 min + 2×60 min = 6 units), Month 3 (4×30 min = 4 units) → Total 18 units
