CurrentAnthemPolicy N/A

Request for Authorization: Autism Spectrum Disorder (ASD) Psychological Testing

Form and instructions governing prior authorization requests for formal psychological testing for autism spectrum disorder for Anthem Wisconsin (BadgerCare Plus and Medicaid SSI) members; affects providers requesting ASD testing services.

Policy Summary

PayerAnthem

PolicyASD psychological testing authorization form (Wisconsin)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization via the Anthem/Availity ASD testing form with required clinical assessment items and supporting records attached.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

96130-96139CPT codes listed

WisconsinState program

ASD-onlyForm scope

Coverage Criteria for ASD Psychological Testing

inv-01: Initial authorization criteria

Authorization is considered when formal testing is needed after completion of baseline assessments and when testing will answer unresolved diagnostic questions and affect treatment.

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Pre-authorization prerequisites: All of the following must be documented prior to authorization: completed psychiatric and medical history; clinical interview with the patient; interviews with family members as appropriate; direct observation of the patient; evaluation by speech-language pathologist when indicated; structured developmental and social history; review of academic records/IEP; relevant screening measures (e.g., ASRS, SCQ, SRS, MCHAT, CARS, GARS, GADS); medical evaluation including hearing and vision screening; brief inventories and/or screening measures; and documentation of how testing results will impact the course of treatment.

Form includes checklist of required assessment elements and screener results to attach.

inv-02: Non-covered uses

Non-covered conditions

Excluded request purposes: Requests for placement purposes, disability evaluations, forensic purposes, and educational testing or learning disability assessments are not covered under this form and should be referred appropriately (e.g., public school system for educational testing).

Explicit non-covered uses listed on form.

Requests for testing submitted solely for placement purposes, disability evaluations, or forensic purposes are not covered under this authorization form. Requests for educational testing or learning disability assessment should be referred to the public school system. This form is specific to autism spectrum disorder testing and does not replace the requisite forms for other psychological or neuropsychological testing.

Formal psychological testing is not clinically indicated for routine screening or for the administration of brief behavior screening measures and inventories. Except in exceptional cases, the psychologist must complete a diagnostic interview and relevant screening measures prior to submitting a request for psychological testing authorization. Testing requests should document remaining diagnostic or clinical questions that were not resolved by interview, record review, and screening.

Requested / Listed CPT Codes

Requested/Listed CPT CodesCPT

96130	Psychological testing evaluation services (one unit maximum) — listed on form
96131	Psychological testing evaluation services — listed on form
96136	Psychological or neuropsychological test administration and scoring — listed on form
96137	Psychological or neuropsychological test administration and scoring — listed on form
96138	Psychological or neuropsychological test administration and scoring (one unit maximum) — listed on form
96139	Psychological or neuropsychological test administration and scoring — listed on form

Provider Action Requirements and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed psychological testing CPT codes for Autism Spectrum Disorder (ASD). Submit prior authorization requests using Anthem/Availity (Availity Essentials) prior to rendering services. This ASD testing authorization form must be completed and submitted online through Availity Essentials or via the Anthem WI provider link. Requests for psychological or neuropsychological testing must use the appropriate requisite forms.

Prior authorization required via Availity/Anthem before services are rendered.
This form is specific to ASD testing; use requisite forms for other psychological/neuropsychological testing.
Requests for placement, disability, forensic evaluations, and educational testing are not covered benefits and should not be submitted on this form.

Documentation Required

Required Supporting Documentation

The following supporting documentation must be submitted with the authorization request. Attach relevant clinical and medical records that support the medical necessity of testing. Ensure documentation addresses the diagnostic uncertainty and demonstrates that pre-testing clinical assessment and screening measures were completed.

Completed clinical assessment items (checklist): psychiatric and medical history; clinical interview with patient; interview with family members; direct observation; structured developmental and social history; review of academic records/IEP; evaluation by speech-language pathologist; consultation with school/important persons; developmental screening by physician/psychologist; complete medical evaluation with hearing and vision screening.
Date of diagnostic interview and copies of any relevant clinical or medical records.
Screening measures administered and results (examples: ASRS, SCQ, SRS, M-CHAT, CARS, GARS, GADS, or other specified screeners).
Treatment history: frequency and duration of services (mental health/behavioral therapy, medication management, speech/occupational therapy, early childhood intervention), current treatment status, and response to treatment.
Previous ASD testing details (dates, test types, results) and rationale for retesting if applicable.
Rationale for testing: specific diagnostic/clinical questions remaining, and how test results will impact treatment (indicate if request is to access ABA services).
Specific tests and services requested: list CPT codes and test names (for tests with multiple versions specify version; if administering selected subtests, indicate which subtests). Example CPTs: 96130 (one unit maximum), 96131, 96136. Include units and names of evaluation services/tests to be administered.

Note

Pre-testing Clinical Assessment and Non-covered Request Types

Psychological testing is not clinically indicated for routine screening or administration of brief behavioral screening measures and inventories. The psychologist should complete a diagnostic interview and relevant screening measures prior to submission of testing authorization except in exceptional cases. Requests for placement purposes, disability evaluations, forensic purposes, or educational testing are not covered benefits.

Do not submit requests for placement, disability, or forensic evaluations — these are not covered.
Refer educational testing or learning disability assessments to the public school system.
Ensure routine screening measures are part of the diagnostic process but do not substitute for the required comprehensive assessment prior to authorization.

Background and Intended Use

Formal psychological testing for autism spectrum disorder is intended to address unresolved diagnostic questions that remain after completion of a diagnostic interview, review of records, and appropriate screening measures. Testing should be pursued only when these baseline clinical assessments have been completed and when test results are expected to influence diagnosis or treatment planning.

Form and Definition

ASD testing request form

Form scopeThis authorization form is specific to autism spectrum disorder (ASD) testing only; other psychological or neuropsychological testing must be submitted on their requisite forms.

Separate requests requiredRequests for other types of psychological or neuropsychological testing (e.g., non‑ASD evaluations) require completion of the appropriate separate authorization form.

Non‑substitutableDo not use this ASD testing form for placement, disability, forensic, or educational testing; such requests are not covered under this form and should be referred as specified.

Clinical prerequisite expectationPsychologist should complete diagnostic interview and relevant screening measures prior to submitting an ASD testing request (except in exceptional cases).

Referral instruction for educational testingEducational testing or assessment of learning disabilities should be referred to the public school system rather than submitted on this form.