BH Recovery Support Navigator (RNS) Form

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Recovery Support Navigator (RSN)- Behavioral Health Policy

 Updated Revision Effective: November 1, 2025

Policy Number: UM1029POL

Approval Date: 9/9/2025

Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description
Recovery Support Navigator (RSN) services are staffed by paraprofessionals who provide care management and system navigation support to Members with a diagnosis of substance use disorder and/or co-occurring mental health disorders. The purpose of RSN services is to engage Members as they present in the treatment system and support them in accessing treatment services and community resources.

Members can access RSN services based on medical necessity and/or a referral by a medical or behavioral health provider, Community Partner (CP), or other care manager, who has contact with the Member and is able to identify the need for RSN services.

RSN services are appropriate for Members with substance use disorder (SUD) and/or co-occurring disorders who are in need of additional support in remaining engaged in treatment; identifying and accessing treatment and recovery resources in the community including prescribers for addiction and psychiatric medications; and/or developing and implementing personal goals and objectives around treatment and recovery from addiction and/or co-occurring disorders. The RSN explores treatment recovery options with the Member, helps clarify goals and strategies, provides education and resources, and assists Members in accessing treatment and community supports. The RSN is not responsible for a Member's comprehensive care plan or medical or clinical service delivery, but supports the Member in accessing those services and participates as part of the overall care team when appropriate.

The RSN service is based within a licensed behavioral health outpatient clinic or an opioid treatment center, and RSNs can be deployed to any setting.

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 Line of Business

Commercial: Fully funded and GIC: Refer to the criteria under the Policy section in this policy.

Medicaid – BeHealthy:
Review is performed by the Massachusetts Behavioral Health Partnership (MBHP).

Medicare:
This policy does not apply.

Policy
Coverage Criteria: All of the following criteria are necessary for admission to this level of care*:

1. The Member demonstrates symptomatology consistent with a DSM-5-TR diagnosis for a substance use disorder, which requires and can reasonably be expected to respond to therapeutic intervention.

   And at least one (1) of the following:

2. The Member is at a transition point in their treatment and/or recovery and/or at risk for admission to 24-hour behavioral health inpatient/diversionary services, as evidenced by one or more of the following: a. Discharge from a 24-hour behavioral health inpatient/diversionary level of care within the past 180 days; b. Multiple Adult Mobile Crisis Intervention (AMCI) and/or emergency department (ED) encounters within the past 90 days; c. Documented barriers to accessing and/or consistently utilizing essential medical and behavioral health services; d. Initiating or changing an addiction pharmacotherapy or medication-assisted treatment (MAT) regimen and/or changing MAT provider; e. Loss of employment within 90 days; f. Loss of family support and connection within 90 days; or g. Currently pregnant or up to 12 months postpartum, with or without custody. Exclusion Criteria Any of the following criteria may be sufficient for exclusion from this level of care:

3. The Member is at acute risk to harm self or others, or sufficient impairment exists to require a more-intensive level of service beyond community-based intervention.
4. The Member has severe medical conditions or impairments that would prevent beneficial utilization of services.
5. The Member is receiving similar supportive services and does not require this level of care.
6. The Member, and their parent/guardian/caregiver when applicable, does not consent to RSN services.

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Continued Stay Criteria All the following criteria are necessary for continuing in treatment at this level of care:

1. Severity of illness and resulting impairment continue to warrant this level of care in order to maintain the Member in the community and continue progress toward RSN service plan goals and clinical treatment plan goals.
2. The Member's treatment does not require a more intensive level of care, and no less-intensive level of care would be appropriate or is available.
3. After initial evaluation and stabilization, it is determined that the presenting symptomatology is indicative of a DSM-5-TR diagnosis (inclusive of psychosocial and contextual factors and disability, as applicable), which is amenable to continued services at this level of care. Conditions that would not be appropriate for continued RSN services are: a. Permanent cognitive dysfunction without acute DSM-5-TR diagnosis. b. Medical illness requiring treatment in a medical setting. c. Chronic conditions with no indication of need for ongoing services at this level of care to maintain stability and function.
4. RSN services are rendered in an appropriate manner and focused on the Member's behavioral and functional outcomes as described in the RSN service and discharge plans.
5. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of RSN services and treatment services have not yet been achieved, or adjustments in the RSN service plan to address lack of progress are documented.
6. The Member is actively participating in the RSN service plan and related treatment services, to the extent possible consistent with the Member's condition. Any barriers to active participation are outlined with specific goals to address and resolve in the service place.
7. Unless contraindicated, the family, guardian, and/or natural supports are actively involved in RSN services.

8. When medically necessary, the Member has been referred to appropriate psychopharmacological services. Discharge Criteria Any of the following criteria is sufficient for discharge from this level of care:

9. The Member no longer meets admission criteria or meets criteria for a less- or more-intensive level of care.
10. RSN service plan goals and objectives have been substantially met and/or a safe, continuing care program can be arranged and deployed at a less-intensive level of care.
11. Consent for the RSN service is withdrawn. In addition, it has been determined that the Member, parent, and/or guardian has the capacity to make an informed decision, and the Member does not meet the criteria for a more-intensive level of care.
12. Support systems that allow the Member to be maintained in a less-restrictive treatment environment have been secured.

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Policy Guidelines and Definitions

HNE has adopted the Mass Health medical necessity guidelines for this outpatient service. 1 unit of service = 15 minutes of provided services to the member.

Coding Guidance

Code
Description
PA H2015-HF Comprehensive community support services, per 15 minutes Yes

CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References Mass Health Medical Necessity criteria

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 1/1/2025 Initial policy date 8/2025 No changes

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Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.