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Sustainability Spotlight: Western New York Integrated Care 

Collaborative Contracting for Health and Well-Being Coaching

Overview of the Western New York Integrated Care Collaborative

Western New York Integrated Care Collaborative (WNYICC) is a Community Care Hub (CCH) operating 

across the entire Western New York Region. The CCH operates a network with over 40 communitybased organizations (CBOs) that provide direct services, including post-discharge meals, care 

coordination, and evidence-based programs (e.g., Diabetes Prevention Program, falls prevention, 

chronic disease self-management). WNYICC provides a centralized IT platform for all their CBOs to 

document assessments for health-related social needs (HRSNs), deploy HRSN interventions, and document the 

outcomes of interventions for identified HRSNs. WNYICC centralizes the contracting process and provides training to 

their CBO members on the interventions that are currently contracted. Additionally, WNYICC implements a continuous 

quality improvement process to ensure that all CBOs provide high quality services. Maintaining such a role is core to the 

responsibilities of a CCH. A list of the WNYICC network members can be found on their website: 

https://www.wnyicc.org/About/Network-Members.

WNYICC Contracting History with Independent Health Medicare Advantage (MA) Plan

WNYICC’s first contract as a CCH was a special supplemental benefit for the chronically ill (SSBCI) 

benefit to provide post-discharge meals to Independent Health’s MA plan members. WNYICC 

worked with Independent Health to conduct an evaluation of the SSBCI post-discharge meal 

benefit, assessing the impact of the meal benefit on readmissions. The evaluation revealed that 

persons with multiple chronic conditions benefitted most from the post-discharge meal 

intervention. Based on the evaluation data, Independent Health agreed to provide an expanded 

intervention that includes HRSN screening and ongoing health coaching. 

Health Coaching CPT Code Overview

The American Medical Association (AMA) approved a set of Category III Current Procedural Terminology (CPT) codes for 

Health and Well-Being Coaching effective January 1, 2020. The Category III CPT codes for Health and Well-Being 

Coaching are:

• 0591T: Health and Well-being Coaching face-to-face; individual, initial assessment

• 0592T: Individual, follow-up session, at least 30 minutes

• 0593T: Group (two or more individuals), at least 30 minutes

Effective July 1, 2022, AMA provided an updated definition of a Health and Well-Being Coach as it applies to the Health 

Coaching Category III code. The current definition removes the requirement that the Health Coach completes a training 

by a health coaching program accredited by the National Board for Health & Wellness Coaching (NBHWC). The current 

CPT definition of a Health Coach is the following:

“Health and well-being coaching is a patient-centered approach wherein patients determine their goals, use selfdiscovery or active learning processes together with content education to work toward their goals, and self-monitor 

behaviors to increase accountability, all within the context of an interpersonal relationship 

with a coach. The health and well-being coach is qualified to perform health and well-being 

coaching by education, training, national examination, and, when applicable, 

licensure/regulation, and has completed a training program in health and well-being 

coaching whose content meets standards established by an applicable national 

credentialing organization. The training includes behavioral change theory, motivational 

strategies, communication techniques, health education and promotion theories, which are 

used to assist patients to develop intrinsic motivation and obtain skills to create sustainable 

change for improved health and well-being.” (American Medical Association [AMA] CPT® 

Category III Codes. Most Recent Changes to the CPT® Category III Codes document. 

December 30, 2021.)
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WNYICC Health Coaching Intervention

WNYICC developed a health coaching intervention that focuses on screening and addressing HRSNs by providing health 

coaching for persons with a recent hospitalization who have multiple chronic conditions. The contract with Independent 

Health requires the CCH to file claims for all services. WNYICC leadership conducted a review of available billing codes 

for Health Coaching services revealing a set of Health Coaching Codes that were approved by the AMA in 2020. At the 

time, Health Coaches were required to obtain training from a health coaching program accredited by NBHWC. This 

requirement disqualified WNYICC program staff because most persons working as Health Coaches did not obtain their 

training from a NMBHWC accredited program. Fortunately, due to the updated CPT guidelines in 2022, WNYICC could 

proceed to use this code as the basis for the SSBCI Health Coaching benefit. 

Once WNYICC secured agreement with Independent Health to establish a Health Coaching 

benefit, WNYICC needed get their health coaches credentialed with Independent Health. The 

credentialing process includes defining the labor category of the persons who will provide the 

Health Coaching service. A taxonomy code is often required by health plans to complete the 

credentialing process and be formally approved to provide services to health plan members. 

Separate from the Health Coaching CPT codes, there is a taxonomy code defined for Health 

Coaches, which became effective on April 1, 2021. WNYICC used the taxonomy code for 

health coaches to complete the required credentialing process with Independent Health. 

Upon identification of the appropriate CPT and taxonomy codes, Independent Health then began testing claims in 

partnership with WNYICC to integrate the new codes into their technology system. The system had to create a charge 

capture process that linked the service to the Health Coaching codes. The codes have to be pulled into an electronic 

1500 claim form, also known as an 837 electronic claim. The 837 test claim was filed to Independent Health as a zero 

dollar ($0.00) claim to determine if the test claim could be processed. Once the claim was successfully processed for 

payment, Independent Health approved WNYICC to file claims for Health Coaching in CY2023.

Key Accomplishments to Date

The health plan requested WNYICC incorporate Z code reporting into their claiming processfor 

each Health Coaching intervention. In response, WNYICC completed a crosswalk of their HRSN 

screening tool with relevant Z codes. WNYICC is using a HRSN tool that enhances the questions 

in the CMS Accountable Health Communities (AHC) Health-Related Social Needs (HRSN)

Screening Tool. The CMS AHC HRSN screening tool can be found on their website: 

https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf.

Next, WNYICC trained their Health Coaches on Z codes and incorporated Z code reporting 

requirements for each health plan member enrolled in the Health Coaching program. Third, 

WNYICC developed formal processes to capture and report Z codes on electronic claims for all 

identified HRSNs that are discovered during the screen or identified during the Health Coaching 

intervention. Lastly, WNYICC developed a process to aggregate Z code data and will conduct regular needs assessments 

for the target population. WNYICC plans to coordinate with Independent Health’s population health team to deploy 

interventions based on the priority HRSNs impacting the target population. Independent Health successfully launched 

the Health Coaching SSBCI benefit on January 1, 2023.

For More Information

Visit the Administration for Community Living’s (ACL) website on Advancing Partnerships to Align 

Health Care and Human Services: https://acl.gov/programs/strengthening-aging-and-disabilitynetworks/improving-business-practices

Contact ACL at communitycarehubs@acl.hhs.gov