Family-based Intensive Treatment (FIT) coverage criteria for Medicaid members
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Defines coverage, prior authorization, billing, and operational requirements for Family-based Intensive Treatment (FIT) for Medicaid members under age 21 at acute risk of hospitalization or recently hospitalized, effective October 1, 2025. Applies to providers delivering FIT in the specified state program.
Family-based Intensive Treatment (FIT) service is available effective October 1, 2025 for high-risk Medicaid members.
FIT uses a fixed Sunday–Saturday 7-day unit for authorizations and billing regardless of enrollment day.
Prior authorization is required for initiation and ongoing FIT treatment and decisions are based on Medical Necessity Criteria.
Coverage and Eligibility for FIT
Initial FIT Coverage Criteria
Covered when ALL of the following are met
From overview
Billing and provider restriction
Initial PA authorizes one 7-day unit; reauthorization required 7 days after enrollment and then every 14 days; authorizations use a fixed Sunday–Saturday 7-day unit
Coverage for Family-based Intensive Treatment (FIT) is restricted to delivery by authorized Community Service Agencies. Only these provider entities are permitted to furnish FIT and bill the Managed Care Entity using the FIT encounter bundle code H0046 HT. This billing restriction applies regardless of setting or modality, as the single weekly bundle covers all professional/licensure levels and places of service.
When a requested FIT service does not meet the plan's Medical Necessity Criteria, the request will be denied and the determination communicated to the provider and member with instructions. Denial notices will include the member’s and provider’s appeal rights and the procedures for submitting an appeal as described in the policy.
Billing, Codes, and Authorization Units
| H0046 HT | Mental health services, not otherwise specified (Family-based Intensive Treatment per week) / HCPCS-Non-Therapy Per Diem |
| H0037 | Service code listed on sample authorization |
| H0040 | Service code listed on sample authorization |
| H0040 HT | Service code listed on sample authorization |
| H0041 | Service code listed on sample authorization |
| H2013 | Service code listed on sample authorization |
| H2016 | Service code listed on sample authorization |
| H2018 | Service code listed on sample authorization |
| H2020 | Service code listed on sample authorization |
| H2022 | Service code listed on sample authorization |
| H2031 | Service code listed on sample authorization |
Prior Authorization, Submission, and Appeals
Prior Authorization Required
Family-based Intensive Treatment (FIT) services require prior authorization (PA) for both initiation and ongoing treatment. Decisions are made based on the Medical Necessity Criteria. The initial PA must be submitted using the FIT prior authorization request form on Provider Express and authorizes one 7-day unit (Sunday–Saturday).
- Initial PA: submit the FIT prior authorization request form on the Mass. page of Provider Express with member details and provider attestation that the member meets Medical Necessity Criteria.
- Initial authorization authorizes one 7-day unit (fixed Sunday–Saturday) regardless of approval date; e.g., approval on Wednesday covers the 7-day unit beginning the previous Sunday.
- Ongoing/continuation: reauthorization is required 7 calendar days after enrollment for the first reauthorization and every 14 days thereafter; approved reauthorizations typically authorize two 7-day units (14 days).
- Providers must submit reauthorization requests on the same day of week as the member’s initial enrollment (to maintain the Sunday–Saturday structure).
PA Submission Documentation
Submit the FIT prior authorization request form on Provider Express and include the required member and provider attestations. If additional information is needed, a licensed Care Advocate may request further details or a peer review (by phone or online).
- Form located on the Mass. page of Provider Express.
- Form requires provider attestation that the member meets Medical Necessity Criteria.
- If incomplete, Care Advocate may request additional documentation or initiate peer review.
Authorization Confirmation Contents
If services are approved you will receive immediate digital confirmation and a mailed letter. The authorization confirmation will include the member’s information, the authorization number, units authorized, effective/expiration dates, and service code validation showing H0046 HT to indicate FIT authorization. Keep the confirmation for billing and audit purposes.
- Authorization confirmation includes: member name and ID, approval/authorization number, units authorized (7-day unit counts), onset/effective and end dates, and the FIT billing code H0046 HT appearing in Service Codes.
- Digital confirmation is immediate; a USPS letter is also sent for records.
Denial Triggers and Appeals
Denials will be issued when the Medical Necessity Criteria are not met or required documentation/attestations are missing. Providers have the right to appeal denials per Optum procedures.
- Denial triggers: failure to meet Medical Necessity Criteria, incomplete or missing FIT PA form attestations, or lack of requested supporting documentation.
- If denied, follow the Optum appeal process and timelines outlined on Provider Express; include clinical rationale and any additional supporting documentation when requesting reconsideration.
Program Background and Scope
Family-based Intensive Treatment (FIT) is a short-term, intensive therapeutic and case management service for individuals younger than 21 who are at acute risk of hospitalization or have been recently hospitalized. FIT is designed to maintain safety in the home and connect the youth and family to longer-term supports. Services are delivered as a weekly encounter bundle billed under H0046 HT, which covers all professional/licensure levels, places of service, and delivery modalities for the week.
Key Definitions
Service Intensity and Setting
Outpatient / Home-based intensive service
FIT is a short-term intensive in-home service for members under 21 at acute risk or recently hospitalized
Providers must submit reauthorization requests on the same weekday as the initial enrollment for the duration of FIT services
H0046 HT covers all professional/licensure levels, places of service, and delivery modalities
FIT Treatment Modalities
Family-based Intensive Treatment (FIT)
Single bundle rate covers modalities
Authorization Cadence and Visit Limits
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