CurrentAnthemPolicy N/A

Functional Family Therapy (FFT) — Initial Service Authorization (H0036)

Authorization form and medical necessity/admission criteria for Functional Family Therapy (H0036) for youth, describing provider submission requirements and clinical admission/discharge planning; intended for providers requesting initial FFT services for Medicaid members.

Policy Summary

PayerAnthem

PolicyFunctional Family Therapy (FFT) — Initial Service Authorization (H0036)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDecember 2021

Next Review DateN/A

Key ActionSubmit the FFT (H0036) Initial Service Authorization Request Form with required provider/member information, proposed dates/units, prior FFT treatment history, and supporting assessment documents.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

11-18target youth age range

H0036procedure/service code

7document id / pages

Coverage Criteria for Functional Family Therapy (FFT)

inv-01: Initial Admission Criteria

Covered when ALL of the following are met:

FFT Admission Criteria #1-7: 1) Age: Youth is generally 11–18 years; if outside this range, justification for need/appropriateness of FFT is required.

FFT Admission Criteria #1-7: 2) Primary diagnosis: The primary DSM diagnosis must be in disruptive behavior, mood, substance use, or traumatic stress. Document current symptoms (frequency, intensity, duration) and areas of functional impairment.

FFT Admission Criteria #1-7

Risk indicators (select ONE)
- A: Persistent and deliberate attempts to intentionally inflict serious injury on another person (provide details and dates when feasible).

Policy Summary

PayerAnthem

PolicyFunctional Family Therapy (FFT) — Initial Service Authorization (H0036)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDecember 2021

Next Review DateN/A

SourceLink

On This Page

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B: Ongoing dangerous or destructive behavior that endangers self/others, is difficult to control, causes distress, or negatively affects health (describe repeated occurrences).

C: Increasing and persistent symptoms of depression or anxiety combined with externalizing behaviors contributing to decreased community functioning (describe how symptoms have been increasing/persistent over last 30 days).

D: Ongoing substance use or dependency interfering with interpersonal relationships and community functioning (specify substances, use patterns, and impacts).

FFT Admission Criteria #1-7: 4) Step-down from out-of-home placement: FFT may be indicated when the youth is returning home from an out-of-home placement; provide placement name, reasons for admission, treatments received, and response to treatment.

FFT Admission Criteria #1-7: 5) Family/caregiver participation: Identify family member(s)/caregiver(s) available to participate in FFT services with the youth.

FFT Admission Criteria #1-7: 6) Safety/supervision arrangements: Describe arrangements for supervision at home/community to ensure a reasonable degree of safety for participation; attach or cite an established safety plan if applicable.

FFT Admission Criteria #1-7: 7) Rationale for FFT: Describe how successful reintegration/maintenance in the community depends on an integrated, coordinated, intensive family/caregiver approach and why the FFT model is the best fit for the youth's problem behaviors.

The FFT initial authorization form explicitly requests disclosure of other medical or behavioral health concerns that could impact services. Examples listed on the form include substance use issues, personality disorders, dementia, and cognitive impairments; providers must indicate Yes/No and explain if present.

Authorization for FFT is contingent on meeting the program's admission requirements: the form states that individuals must meet ALL of the criteria #1-7. Failure to demonstrate that the member satisfies each required criterion (for example age range, primary DSM diagnosis, or recent risk indicators) will render the service not authorized.

Service Codes and Billing

Referenced service codeHCPCSCovered

H0036

Functional Family Therapy

Provider Submission and Documentation Requirements

Documentation Required

Required submission documents

Complete and submit the Functional Family Therapy (H0036) Initial Service Authorization Request Form. The form must include provider and member identification, proposed dates/units of service, and documentation of any FFT treatment periods in the past 12 months.

Functional Family Therapy (H0036) Initial Service Authorization Request Form must be attached
Include provider name, NPI, Tax ID, phone, email, address, clinical contact with credentials and phone
Include member name, date of birth, plan/ID numbers, Medicaid #, address, guardian contact if applicable
If member currently receiving FFT, provide start date and proposed service dates/units
Identify all known FFT treatment periods in past 12 months with provider, dates, outcomes

Prior Authorization

Prior treatment history and rationale

The Initial Authorization form requires a clear prior treatment history and clinical rationale explaining why FFT is the most appropriate intervention. Document prior treatments, responses, and why FFT is a better fit than alternatives.

Describe previous behavioral health treatments, dates, providers, and outcomes
Explain why FFT is the best fit for the youth’s current problem behaviors and how it will address family/caregiver involvement
If returning from out-of-home placement, provide placement name, reason for admission, treatments received there, and response to those treatments

Denial Risk

Admission criteria not met — risk of non-authorization

The form includes admission criteria; failure to demonstrate the youth meets ALL admission items #1–7 will result in non-authorization. Ensure documentation addresses age range, primary DSM/ICD-10 diagnosis, symptom presentation and functional impairment, risk indicators for out-of-home placement, family/caregiver availability, and safety/supervision arrangements.

Confirm youth age (11–18) or provide justification if outside range
Provide primary DSM diagnosis (disruptive behavior, mood, substance use, or traumatic stress) and describe symptoms (frequency, intensity, duration) and functional impairment
Document at least one recent (past 30 days) risk indicator that places youth at risk of out-of-home placement (A–D) or that youth is returning from out-of-home placement (E)
Describe family/caregiver identity and relationship and ability to participate in FFT
Include arrangements for supervision/safety plan at home or community (attach safety plan if available)

Background on Functional Family Therapy

Functional Family Therapy (FFT) is described as a family-based intervention intended for youth with behavioral health problems and is used to address family engagement and youth problem behaviors to reduce the risk of out-of-home placement. The form emphasizes youth generally aged 11–18 years with primary diagnoses in disruptive behavior, mood, substance use, or traumatic stress and documents recent risk indicators (within the past 30 calendar days) such as persistent attempts to harm others, ongoing dangerous/destructive behavior, worsening depression/anxiety with externalizing behaviors, or ongoing substance use that impairs functioning.

Key Definitions and Admission Components

Initial Admission Criteria

Admission requirementIndividuals must meet ALL of the criteria #1-7; some items include multiple sub-criteria (age, primary DSM diagnosis categories, recent risk behaviors within 30 days, caregiver availability, safety/supervision, step-down justification, and provider rationale).

AgeYouth generally 11–18 years; if outside this range, provide justification for need and appropriateness of FFT.

Primary diagnosisPrimary DSM diagnosis must be in disruptive behavior, mood, substance use, or traumatic stress (corresponding to ICD-10 diagnoses listed on the form) with description of current symptoms and functional impairment.

Recent risk indicators (past 30 days)Must have at least one of: A) persistent deliberate attempts to inflict serious injury on another; B) ongoing dangerous/destructive behavior; C) increasing/persistent depression or anxiety combined with externalizing behaviors causing decreased community functioning; D) ongoing substance use/dependency impacting relationships and functioning.

Step-down placementFFT may be indicated as a step-down service for youth returning home from an out-of-home placement; documentation requested.

Family/caregiver participation & safetyIdentification of family/caregivers available to participate and arrangements for supervision/safety at home or in the community (include safety plan if applicable).

Provider rationaleProvider must describe why integrated family-focused FFT is necessary for reintegration/maintenance and why FFT fits the youth's problem behaviors.

Outpatient / Community-based FFT Eligibility

Treatment Modalities: Functional Family Therapy

inv-12: Functional Family Therapy (FFT)

Treatment documentation: Behavior Change Session Plan used in FFT supervision may serve as the Individualized Service Plan; fidelity to the FFT model and supervision/consultation documentation may be attached to the authorization request.

Service Duration and Units

Requested Service Period / Units

Requested service dates and unitsForm requests 'From (date), To (date), for a total of units of service.' Specific numeric unit limits are not provided in the document.

Prior FFT treatment historyForm requests identification of all known treatment periods of Functional Family Therapy provided by any providers in the past 12 months (provider, dates of service/intervention, outcomes).

Member identifiersProvider must include member identifiers (e.g., Medicaid #, Member DOB, Member Plan ID) alongside proposed service dates/units.

Clinical contact and documentationForm includes fields for clinical contact name/credentials and requests supporting assessment documents (implied elsewhere on form).