Recovery Coaching (RC) Form

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Recovery Coaching (RC) Behavioral Health Policy New Policy Effective: January 1, 2025 Policy Number: UM1028POL

Approval Date: 11/20/2024

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

Description
Recovery Coaches (RCs) are individuals currently in recovery who have lived experience with substance use disorders and/or co-occurring mental health disorders and have been trained to help their peers who have a similar experience to gain hope, explore recovery, and achieve life goals.

RCs are actively engaged in their own personal recovery and share real-world knowledge and experience with others who are on their own recovery path. RCs share their recovery story and personal experiences in an effort to establish an equitable relationship and support Members in obtaining and maintaining recovery.

The primary responsibility of RCs is to support the voices and choices of the Members they support. The focus of the RC role is to create a relationship between equals that is non-clinical and focused on removing obstacles to recovery; linking Members to the recovery community and serving as a personal guide and mentor. The RC will work with the Member to develop a Wellness Plan that orients the activities of the RC service.

Members can access RC services based on medical necessity and 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 RC services. Services are available to members seeking to achieve or maintain recovery from substance use and/or co-occurring disorders and Members of at-risk populations such as pregnant and postpartum, Members identified with barriers of social determinants of health, and medically complex Members.

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 Line of Business

Commercial (fully funded and GIC) Refer to 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 (SUD).

2. And at least one (1) of the following: a. The Member is attempting to achieve and/or maintain recovery from substance use and/or co- occurring disorders. b. The Member could benefit from education about harm reduction and/or education about recovery and community resources. c. The Member could benefit from support in increasing motivation and readiness to change.
   The Member could benefit from peer support in establishing connections with the recovery community. d. The Member could benefit from the structure of a Wellness Plan. OR e. The Member is referred by a primary care provider for assistance with the necessary medical follow- up.

   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 RC services.

   Continued Stay Criteria

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

7. The Member is actively involved with the RC and are making connection at a minimum of one contact every 21 days.
8. The Member is actively addressing the components of the Wellness Plan and making adjustments as needed.
9. There is documented, active coordination of services with other behavioral health providers, the primary care provider, and other services and state agencies. If coordination is not successful, the reasons are documented, and efforts to coordinate services continue.
10. There is documented, active discharge planning starting with admission to RC services.
11. When medically necessary, the Member is supported in accessing appropriate
    psychopharmacological services.

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Discharge Criteria Any of the following criteria is sufficient for discharge from this level of care:

1. The Member no longer meets admission criteria.
2. RC Wellness Plan goals and objectives have been met.
3. The Member or Member and parent and/or legal guardian is/are not utilizing or engaged in the RC service as demonstrated by fewer than one contact every 21 days.
4. Consent for RC services is withdrawn.

5. Support systems that allow the Member to be maintained in the community have been established.

   Coding Guidance

   Recovery Coaching is billed as 1 unit which is equivalent to 1 day, max 1 unit a day.

   Code
   Description
   PA H2016HM Comprehensive community support services, per diem 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 HNE is utilizing the Mass Health Medical Necessity Criteria for this level of care.

   Policy Implementation

   Approved by the Medical and Pharmacy Policy Committee

   Kate McIntosh MD MBA

   Chief Medical Officer

   Saad Usmani MD MBA

   Medical Director

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Date Update 1/1/25 Initial policy date

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.