Currentblue cross blue shield - michiganPolicy N/A

Outpatient Provider-Delivered Care Management (AIS and CIS) Coverage Criteria

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Defines clinical program requirements, staffing, levels of care, coding and prior authorization rules for Adult Intensive Services (AIS) and Children's Intensive Services (CIS) for Blue Cross Blue Shield of Michigan and Blue Care Network members.

Policy Summary

Payerblue cross blue shield - michigan

PolicyOutpatient Provider-Delivered Care Management (AIS and CIS) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 1, 2025

Last ReviewNov 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for autism-related codes 97151–97158 and ensure a psychiatrist (MD/DO) orders and signs AIS/CIS services.

SourceLink

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Currentblue cross blue shield - michiganPolicy N/A

Outpatient Provider-Delivered Care Management (AIS and CIS) Coverage Criteria

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Sign up for all blue cross blue shield - michigan policy alerts

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Policy Summary

Payerblue cross blue shield - michigan

PolicyOutpatient Provider-Delivered Care Management (AIS and CIS) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 1, 2025

Last ReviewNov 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for autism-related codes 97151–97158 and ensure a psychiatrist (MD/DO) orders and signs AIS/CIS services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Levels of care defined

Up to 90Max monthly hours (Level 3)

99487/99489; 97151–58Procedure codes referenced

>=101Level 3 score threshold

Coverage Criteria for AIS and CIS

General coverage criteria

Covered when services are delivered as outpatient provider-delivered care management through AIS or CIS and meet level-specific criteria and staffing requirements.

Program-level requirements: Program must provide coordinated treatment and support team with required staffing: a psychiatrist (MD or DO) to order and bill for AIS/CIS, program supervisor, team lead/licensed master's-level clinician, behavioral health care manager, and community health worker/peer; develop an individualized treatment plan; coordinate social determinants of health resources; supervise or coordinate interventions (including peer/parent support partners and in-home services).

See program staffing and documentation requirements in clinical program requirements.

Coding and prior authorization: Use CPT codes 99487 and 99489 for complex chronic care management for members without autism (no prior authorization required for those codes); use autism-related procedure codes 97151-97158 for autism services (these require prior authorization).

Providers must verify prior authorization requirements and member eligibility via the payer portal.

Level 1 coverage criteria

Level 1 — typical LOS 2-3 months. Covered when ALL of the following are met:

Staffing and services: Case manager (support coordinator) provides up to 18 hours per month of provider-delivered care management; facilitates and coordinates with involved parties (primary care, therapist, psychiatrist, parents/caregiver, emergent assessment facility), develops the treatment plan, links social determinants of health resources, and supervises or coordinates interventions; parent support partners may complement coordination.Up to 18 hours/month

May include only medication management in some cases.

Member presentation: Member shows regression in behavior or baseline functioning related to changes in family/home/school; medication re-evaluation may be needed; parent engaged but has limited skills and requires support; PECFAS/CAFAS score generally 50-80.PECFAS/CAFAS 50-80

PECFAS/CAFAS ranges are not normed for autism spectrum disorder.

Level 2 coverage criteria

Level 2 — typical LOS 1-2 months. Covered when ALL of the following are met:

Staffing and services: Case manager (support coordinator) provides up to 50 hours per month of provider-delivered care management; may include intensive home-based treatment, peer and parent support partners; develops the treatment plan and links social determinants of health resources; supervises or coordinates interventions.Up to 50 hours/month

Interventions are focused on specific behaviors in the member's environment.

Member presentation: Family is experiencing overwhelming stressors managing care; decrease in but not return to baseline behaviors; limited attempts at self-injury; medication adjustments and monitoring needed; increased frequency of redirection; PECFAS/CAFAS score generally 80-100.PECFAS/CAFAS 80-100

A score of 80 or lower may indicate readiness to transition to a lower level of care.

Level 3 coverage criteria

Level 3 — typical LOS one month or more. Covered when ALL of the following are met for stabilization, urgent assessment, or step-down:

Staffing and services: Case manager (support coordinator) provides up to 90 hours per month of provider-delivered care management; facilitates and coordinates with all parties as needed (including coordination of in-home services), develops the treatment plan, links social determinants of health resources, and supervises or coordinates interventions including parent support partners and in-home respite.Up to 90 hours/month

State-certified parent/peer partners preferred where applicable.

Member presentation (examples): High frequency of redirection/supervision; severe behavioral problems (assaultive aggression, destructive behavior, self-injury, unstable mood, suicidality); medication regimen change required; psychotic symptoms or caregivers out of options; PECFAS/CAFAS 101+.PECFAS/CAFAS >= 101

Used for stabilization, urgent assessment, or step-down planning.

Level 3 (in-home respite and caregiver need)

Level 3 caregiver/care requirements

Level 3 caregiver criteria: All of the following: caregiver is 'out of options' for caregiving; PECFAS/CAFAS score is 101 or more (PECFAS/CAFAS scoring is not normed for autism spectrum disorder).PECFAS/CAFAS >= 101

A score of 100 or lower may indicate readiness to transition to a lower level of care.

Any services not covered by the procedure codes listed for AIS/CIS may be billed separately in accordance with the behavioral health fee schedule. Examples explicitly called out include crisis psychotherapy, psychiatric time, individual or group psychotherapies, and individual therapy with prolonged service codes for extended sessions.

The PECFAS/CAFAS scoring guidance referenced for level assignment does not apply to autism spectrum disorder because these measures are not normed for ASD. The policy notes that Level 3 caregiver criteria reference PECFAS/CAFAS scores of 101 or more, but explicitly states this scoring guidance is not applicable for ASD.

Level of Care Assignment Rules

Level 1 / Level 2 / Level 3

Top-level criteria summary for Levels 1, 2, and 3.

Level 1: Admission/continued stay when member meets Level 1 presentation and staffing/services criteria (PECFAS/CAFAS 50-80); up to 18 hours/month of provider-delivered care management.PECFAS/CAFAS 50-80; up to 18 hrs/month

Typical LOS 2-3 months.

Level 2: Admission/continued stay when member meets Level 2 presentation and staffing/services criteria (PECFAS/CAFAS 80-100); up to 50 hours/month of provider-delivered care management.PECFAS/CAFAS 80-100; up to 50 hrs/month

Typical LOS 1-2 months.

Level 3: Admission/continued stay when member meets Level 3 presentation and staffing/services criteria (PECFAS/CAFAS >=101; caregiver out of options) and requires up to 90 hours/month of provider-delivered care management, including in-home respite where appropriate.

Permitted Treatment Modalities and Program Requirements

Community-based care, in-home respite

Community-based options and in-home respite modalities available for AIS/CIS.

Community-based services: Face-to-face community-based services are preferred for interventions; audiovisual telemedicine may be used in special circumstances. Services should be carried out by community health workers or peer support specialists supervised by a master's-level provider or team lead and coordinated with all involved providers.

Includes development of a treatment plan and linkage to social determinants resources.

In-home respite and services: In-home services including potential in-home respite may be provided as part of Level 3; interventions include supervision/coordination of in-home supports and parent support partners where indicated.

Used when caregivers are out of options and to stabilize the member as indicated in the treatment plan.

Program requirement documents

Documentation and program-level requirements referenced for AIS/CIS.

Procedure Codes and Scoring Bands

Complex chronic care management CPT codesCPTCovered

99487	Complex chronic care management services, first hour
99489	Complex chronic care management, subsequent 30 minutes

Autism spectrum disorder procedure codesCPTCovered

97151	Autism spectrum disorder code
97152	Autism spectrum disorder code
97153	Autism spectrum disorder code
97154	Autism spectrum disorder code
97155	Autism spectrum disorder code
97156	Autism spectrum disorder code
97157	Autism spectrum disorder code
97158	Autism spectrum disorder code

CPT noticemixed

CPT	CPT copyright and trademark notice; specific CPT codes are not listed in these chunks.

PECFAS/CAFAS score bands — Levels 1–2

Level 1 PECFAS/CAFAS range50-80 (note: a score of 49 or lower may indicate readiness for discharge)

Level 2 PECFAS/CAFAS range80-100 (note: a score of 80 or lower may indicate readiness to transition to a lower level)

Readiness thresholds noteScores at or below 100 may indicate readiness to transition to a lower level of care; scores of 81+ may indicate need to consider higher level of care

PECFAS/CAFAS threshold for Level 3

Level 3 PECFAS/CAFAS threshold>= 101

Applicability note

Prior Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Prior Authorization Required for Autism-Related Codes

For outpatient provider-delivered care management services (AIS/CIS), some procedure codes require prior authorization while others do not. Autism spectrum disorder codes 97151–97158 require prior authorization. Complex chronic care management codes 99487 and 99489 do not require prior authorization for members without an autism diagnosis. Failure to obtain required prior authorization for autism-related codes may result in denial of payment.

Affected codes: CPT 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158 (autism-related) — PRIOR AUTHORIZATION REQUIRED
Affected codes: CPT 99487, 99489 (complex chronic care management) — PRIOR AUTHORIZATION NOT REQUIRED

Denial Risk

Eligibility / Benefit Mismatch — Verify Member Coverage

Health plan benefits vary by contract. If services described in this document differ from those available under a member's Blue Cross or BCN contract, the member's contract governs. Providers must check each member's eligibility and benefits before delivering AIS or CIS services.

Provider-Delivered Care Management Hours by Level

Provider-delivered care management hours (per month)

Level 1 provider-delivered care management hoursUp to 18 hours per month

Level 2 provider-delivered care management hoursUp to 50 hours per month

Level 3 provider-delivered care management hoursUp to 90 hours per month

Definitions and Code Descriptions

Procedure code 99487

CPT 99487 descriptionComplex chronic care management services, first hour — one unit billed monthly

Billing rhythmOne unit may be billed monthly for the first hour of services under 99487

Associated programUsed for outpatient provider-delivered care management (AIS/CIS) level assignment and documentation

Procedure code 99489

CPT 99489 descriptionComplex chronic care management, subsequent 30 minutes — total units billed monthly

Unit accounting99489 represents additional 30-minute increments billed in total units for the month

Background and Scope

Outpatient provider-delivered care management offered through Adult Intensive Services (AIS) and Children’s Intensive Services (CIS) provides wraparound support, coordination and direct interventions to help members progress from acute response toward recovery and improved community functioning. These programs require a coordinated treatment and support team, deliver community-based and in-home services (including in-home respite when clinically indicated), develop individualized treatment plans, link members to social-determinants resources, and provide supervised provider-delivered care management hours tailored to level of care.

Policy Summary

Payerblue cross blue shield - michigan

PolicyOutpatient Provider-Delivered Care Management (AIS and CIS) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 1, 2025

Last ReviewNov 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for autism-related codes 97151–97158 and ensure a psychiatrist (MD/DO) orders and signs AIS/CIS services.

SourceLink

On This Page

PECFAS/CAFAS >= 101; up to 90 hrs/month

Typical LOS one month or more.

Level 3 (in-home respite)

Specific criteria for in-home respite under Level 3.

In-home respite indication: In-home respite may be provided when the treatment plan indicates that a brief respite from the living environment is likely to stabilize the member and caregivers are 'out of options'.

In-home respite is part of Level 3 caregiver/services offerings.

Caregiver and scoring requirement: Parent/caregiver is 'out of options' for caregiving AND PECFAS/CAFAS score is 101 or more (note: PECFAS/CAFAS not normed for autism spectrum disorder).PECFAS/CAFAS >= 101

A score of 100 or lower may indicate readiness to transition to a lower level of care.

Program requirement documents: References to other relevant program requirement documents: urgent care and crisis services; opioid treatment programs; partial hospitalization and intensive outpatient programs; feeding and eating disorder PHP/IOP; residential psychiatric treatment; residential treatment for substance use disorders. Use the 'Various behavioral health programs and services' document for links to these requirements.

Providers should follow the specific program documents for modality-specific requirements.

PECFAS/CAFAS scoring not normed for autism spectrum disorder; scores for ASD should not be used for level assignment

Transition considerationA score of 100 or lower may indicate readiness to transition to a lower level of care

PECFAS/CAFAS score suggesting transition readiness

Transition-readiness scorePECFAS/CAFAS <= 100 may suggest readiness to transition to a lower level of care

Contextual notePECFAS/CAFAS guidance does not apply to autism spectrum disorder because the measures are not normed for ASD

Clinical useScores should be considered alongside clinical presentation (behaviors, supervision needs, medication changes) when planning transitions

Check eligibility via the provider portal (e.g., Availity).

Note

Behavioral Health Resources and Authorization Portal

Providers should refer to the Behavioral Health webpage on the payer's authorizations site for authorization guidance, behavioral health resources, and portal access instructions.

Behavioral Health resources and authorization guidance: authorizations.bcbsm.com

Note

Operational Details Not Explicitly Stated — Confirm on Portal

Some operational details and program implications are not explicitly stated in the source chunks (for example, specific prior authorization submission steps, exact documentation templates, and turnaround times). Providers should use the Behavioral Health authorization site and provider portal for the most current operational processes and contact payer support when needed.

Not all authorization process details are specified in these excerpts — confirm submission steps and required documentation on authorizations.bcbsm.com or via the provider portal.

Used to report additional CCM time beyond the first hour billed under 99487

Level 3 — caregivers and services (in-home respite)

In-home respite includedLevel 3 services include in-home respite as part of caregiver supports

Caregiver status triggerApplied when the parent/caregiver is described as 'out of options' for caregiving

Role in interventionsIn-home respite is coordinated by the case manager as part of Level 3 service package

PECFAS / CAFAS scores — role in level assignment

Definition of PECFAS/CAFAS in policyStandardized functioning/needs scores used to inform level assignment; a score of 101 or more is associated with Level 3 caregiver/care need

Norming caveatPECFAS/CAFAS scoring guidance does not apply to autism spectrum disorder because the measures are not normed for ASD

Use in care planningScores are used alongside clinical indicators (severity, supervision needs, suicidality, psychosis, medication changes) to determine level