Community Health 360
✓ TL;DR
- HRSN = individual-level unmet needs (housing, food, transportation). SDOH = community-level conditions.
- Z-codes (Z55–Z65) are how HRSN is documented on claims and in member records.
- CalAIM covers 14 Community Supports, billed fee-for-service through Medi-Cal Managed Care Plans.
- March 2025: CMS rescinded prior HRSN guidance — but approved demonstrations like California continue.
- The workflow is always: Screen → Document → Refer → Bill.
What is HRSN?
Health-Related Social Needs (HRSN) refers to the individual-level social and economic needs that affect a person's ability to maintain their health and well-being — putting them at risk for worse health outcomes and increased health care use. Per CMS, HRSN includes factors like financial instability, lack of access to healthy food, lack of access to affordable and stable housing and utilities, and lack of access to transportation.
What is the difference between HRSN and SDOH?
This distinction trips up a lot of organizations. CMS defines them at two different levels:
| Term | Level | Example |
|---|---|---|
| SDOH Social Drivers of Health |
Community-level conditions — the environments where people are born, live, work, and age. | A neighborhood with no grocery store within 2 miles (food desert). |
| HRSN Health-Related Social Needs |
Individual-level factors — the specific unmet needs a person is experiencing right now. | A specific Medi-Cal member who doesn't have enough food this week. |
Think of SDOH as the context and HRSN as the individual experience of that context.
How does Medicaid cover HRSN?
States can address HRSN through several Medicaid authorities:
- State plan authorities
- Section 1915 home and community-based services (HCBS) waivers
- Managed care "in lieu of services and settings" (ILOS)
- Section 1115 demonstrations
California's CalAIM initiative operates through a Section 1115 waiver, with CMS approval through December 31, 2026.
What changed at the federal level in 2025?
How do CBOs screen for HRSN?
HRSN screening is the starting point for everything — documentation, referrals, and billing all depend on a completed, structured screen. The three most widely used tools are:
PRAPARE
Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences. Widely adopted by FQHCs.
AHC HRSN Screening Tool
Developed by CMS. Covers 10 core domains across 5 key areas. Used to screen 7M+ Medicare and Medicaid beneficiaries.
HealthBegins Upstream Risk
Upstream Risk Screening Tool focused on root-cause social factors driving downstream health outcomes.
Each tool maps to suggested ICD-10-CM Z-codes — the diagnosis codes used to document HRSN findings on claims and in member records.
What are Z-codes and why do they matter?
Z-codes (ICD-10-CM codes Z55–Z65) are the diagnosis codes used to document SDOH and HRSN data — covering issues like housing instability, food insecurity, unemployment, and lack of transportation. Per CMS guidance, Z-codes should be assigned only when documentation specifies that the patient has an associated problem or risk factor influencing their health.
Z-codes matter for CBOs because they:
- Support medical necessity for HRSN services
- Feed into quality reporting and risk adjustment
- Are required on claims for HRSN services in many state programs
- Demonstrate the complexity of care delivered to funders and auditors
Per updated 2026 guidance, quality programs — including HEDIS and Medicaid VBP — now include SDOH screening measures, making consistent Z-code documentation increasingly tied to value-based payment performance.
What does HRSN documentation look like in practice?
Per the DHCS Billing and Invoicing Guidance and state-level requirements, a complete HRSN workflow follows four steps:
- ScreenIdentify the HRSN using a structured tool (PRAPARE, AHC, HealthBegins).
- DocumentRecord the Z-code and a clinical note in the member's record.
- ReferComplete a closed-loop referral to a community service that addresses the identified need.
- BillSubmit the claim using the correct HCPCS codes and modifiers.
How is HRSN billed under CalAIM in California?
Under California's CalAIM, 14 Community Supports are available to Medi-Cal managed care members, launched in January 2022. CBOs contracted to deliver these services bill on a fee-for-service basis through the member's Managed Care Plan using DHCS-established HCPCS codes.
Enhanced Care Management (ECM), by contrast, is billed on a Per Member Per Month (PMPM) basis — a distinction that matters significantly for how CBOs set up their billing workflows.
| Service Type | Billing Model | Codes |
|---|---|---|
| Community Supports (14 services) | Fee-for-service via MCP | DHCS HCPCS + modifiers |
| Enhanced Care Management (ECM) | Per Member Per Month (PMPM) | Bundled monthly rate |
How CH360 helps
Community Health 360 is built specifically for CBOs navigating HRSN documentation and billing. The platform maps your screening results to the correct Z-codes, tracks closed-loop referral confirmations, and structures your records to meet DHCS audit requirements at the point of service delivery.
See how CH360 maps to your state →FAQ
What is HRSN in Medicaid?
HRSN stands for Health-Related Social Needs — individual-level social and economic factors like housing instability, food insecurity, and lack of transportation that affect a person's health outcomes. Per CMS, HRSN is distinct from SDOH, which refers to community-level conditions rather than individual-level needs.
What is the difference between HRSN and SDOH?
SDOH refers to community-level conditions (like neighborhood poverty rates or food desert geography). HRSN refers to individual-level unmet needs (like a specific person not having stable housing this month). Both are documented using ICD-10 Z-codes in clinical and billing records.
What Z-codes are used for HRSN documentation?
ICD-10-CM codes Z55–Z65 cover HRSN and SDOH documentation, including housing instability, food insecurity, unemployment, and lack of transportation. Per CMS, they should only be assigned when documentation confirms an associated problem or risk factor influencing the patient's health.
How do California CBOs bill for HRSN services under CalAIM?
California CBOs contracted to deliver Community Supports bill fee-for-service through the member's Managed Care Plan using DHCS-established HCPCS codes and modifiers. ECM is billed separately on a PMPM basis. CBOs must be contracted and credentialed with the relevant MCP before any claim can be processed.
What software do CBOs use for HRSN documentation?
Most CBOs currently manage HRSN documentation across spreadsheets, generic case management tools, and health plan portals — none of which were built to map screening results to Z-codes or HCPCS billing codes. Purpose-built platforms like Community Health 360 are designed specifically for this end-to-end workflow.
This article was written by the Community Health 360 team. All regulatory references are sourced directly from CMS, DHCS, and OHA.
Sources
- CMS HRSN definition
- Medicaid HRSN authorities (CMS)
- CalAIM HRSN Community Supports Protocol — CMS approval
- DHCS Community Supports HRSN Evaluation
- DHCS ECM and Community Supports Billing Guidance
- DHCS HCPCS Coding Guidance
- CMS Z-Code Resource
- AHC HRSN Screening Tool — CMS
- HRSN Screening Tool Crosswalk
- Federal HRSN policy shift — Health Management Associates