Prior authorization request form Form

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 07|16|2025 POLICY LAST REVIEWED: 07|16|2025 OVERVIEW Adult Intensive Services (AIS) and Child and Family Intensive Treatment (CFIT) are home- and community- based services which are provided to adults and children experiencing moderate to severe psychiatric symptoms. These services may be utilized as a step up from traditional outpatient services or as a step down from more intensive services (such as inpatient hospitalization or residential treatment). The goal of AIS/CFIT is to provide intensive treatment in the least restrictive environment possible. This policy is applicable to Commercial products only. MEDICAL CRITERIA Not applicable NOTIFICATION OF ADMISSION Not applicable POLICY STATEMENT Adult Intensive Services (AIS) and Child and Family Intensive Services (CFIT) benefits are intended to offer treatment to individuals experiencing moderate to severe psychiatric symptoms. Services are generally provided in less restrictive settings (e.g., in the community, in a practitioner's office, and/or in the patient's home) in an effort to reduce inpatient admissions. Although individuals receiving these services are typically not at risk for serious harm to themselves or to others, they may have difficulty performing activities of daily living. If left untreated, these individuals might likely require more intensive care.
Services may include, but are not limited to: • Individual, family, and/or group therapy • Case management coordination • 24/7 emergency crisis evaluation • Psychiatric assessment Adult Intensive Service (AIS) program: AIS benefits are only available to covered adult members after their eighteenth (18th) birthday. Child and Family Intensive Treatment (CFIT) program:
CFIT benefits are only available to covered dependent children until their nineteenth (19th) birthday.
For more information, please contact BCBSRI Behavioral Health Utilization Management at 1-800-274-2958. COVERAGE Benefits may vary by group or contract. Please refer to the appropriate member Benefit Booklet or Subscriber Agreement for applicable behavioral health benefits/coverage. BACKGROUND The intent of this policy is to provide less restrictive behavioral health services to children, adults, and families with intensive behavioral health problems in order to prevent and reduce inpatient admissions. To Payment Policy | Adult Intensive Services (AIS) and Child and Family Intensive Services (CFIT)

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

render AIS/CFIT services in Rhode Island, the facility must be licensed by Behavioral Healthcare, Developmental Disabilities, and Hospitals Department of Rhode Island (BHDDHD) as a Behavioral Health Organization. Providers who are outside of Rhode Island must ensure they have the proper licensing through the state with which they operate.

CODING The provider will be reimbursed at an all-inclusive per unit payment structure. Units are billed per 15-minute increment.

RELATED POLICIES Not applicable

PUBLISHED Provider Update, September 2025 Provider Update, February 2024, May 2024 Provider Update, January 2022, July 2022 Provider Update, June 2021 Provider Update, April 2018, October 2018

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessa ry (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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