CurrentAnthemPolicy N/A

Request for Authorization: Autism Spectrum Disorder Testing (California Medi‑Cal Managed Care)

Form and policy instructions governing prior authorization requests for formal psychological testing for ASD for Anthem members in California (Medi‑Cal Managed Care). It affects providers requesting autism testing services and specifies required documentation and allowed testing codes.

Policy Summary

PayerAnthem

PolicyRequest for Authorization: Autism Spectrum Disorder Testing (CA Medi‑Cal Managed Care)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization via the ASD testing form (or fax) with specified CPT codes/units and attach diagnostic interview, screening results, treatment history, prior testing, and rationale.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Californiajurisdiction

ASD testing formdocument

96130-96139CPT codes

one-unitunit limits

Coverage Criteria for ASD Psychological Testing

Initial authorization criteria

Covered when ALL of the following are met

Pre-authorization clinical evaluation: Psychologist completed a diagnostic interview and relevant screening measures prior to submission; screening results included (e.g., ASRS, SCQ, SRS, MCHAT, CARS, GARS, GADS)

Form instructs these as expected steps

Supporting documentation attached: Attach diagnostic interview date and relevant clinical/medical records (e.g., psychiatric/medical history, clinical interview, family interview, direct observation, speech‑language evaluation, developmental/social history, academic records/IEP), prior ASD testing results with dates and rationale for retest if applicable, and explanation of how testing will change management

See Clinical assessment and Rationale for testing sections

Appropriate screening measures administered: Indicate which screening measures were administered prior to testing request (examples: ASRS, SCQ, SRS, MCHAT, CARS, GARS, GADS) and provide screener results

Policy Summary

PayerAnthem

PolicyRequest for Authorization: Autism Spectrum Disorder Testing (CA Medi‑Cal Managed Care)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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CPT / Billing Codes and Unit Limits

Covered CPT Codes listed on formCPTCovered

96130	Psychological testing evaluation services (one unit maximum noted)
96131	Psychological testing by technician/
96136	Psychological or neuropsychological test administration (one unit maximum noted)
96137	Psychological or neuropsychological test scoring and interpretation
96138	Psychological or neuropsychological test administration (one unit maximum noted)
96139	Psychological or neuropsychological test scoring and interpretation

Unit maximum — select CPT codes

Codes with one-unit maximumCPT 96130, 96136, and 96138 are limited to one unit maximum as indicated on the authorization form.

Other listed CPT codesCPT 96131, 96137, and 96139 are listed on the form without the one-unit maximum note.

Provider must specify unitsThe form requires the provider to indicate Unit(s) for each CPT code selected and total units requested.

Tests/subtests must be specifiedFor each code, the form asks providers to list evaluation services/test names (and specify versions or selected subtests as applicable).

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required via the Anthem ASD psychological testing authorization form (or fax) before rendering the listed CPT codes. Submit the completed form and required documentation prior to providing services.

Affected CPT codes: 96130, 96131, 96136, 96137, 96138, 96139
Fax submissions accepted: 855-473-7902

Documentation Required

Required Supporting Documentation

Attach relevant clinical and medical records to support the testing request. Include date of diagnostic interview, copy of the diagnostic interview summary, and any related medical/behavioral records.

Completed diagnostic interview date and summary
Relevant medical records (history, physical, hearing/vision screens)
Any prior evaluations (speech-language, developmental, school records/IEP)

Documentation Required

Pre-authorization Clinical Steps

Before submitting a prior authorization request, the psychologist should complete a diagnostic interview and administer appropriate screening measures. Document which assessments and screeners were completed and include results.

Clinical assessments to document (select as applicable): psychiatric and medical history, clinical interview with patient, interview with family, direct observation, structured developmental/social history, review of academic records/IEP, evaluation by speech-language pathologist, consultation with school or other providers, developmental screening by physician/psychologist, medical evaluation.
Screeners to administer prior to request: ASRS, SCQ, SRS, M-CHAT, CARS, GARS, GADS (or other relevant measures) — include results.

Denial Risk

Non-covered Purposes and Educational Referrals

Requests for placement, disability determinations, or forensic evaluations are not covered. Refer requests for educational testing or assessment of learning disabilities to the public school system.

Non-covered purposes: placement, disability evaluations, forensic purposes
Educational/learning disability assessments: refer to public schools

Key Definitions

Formal psychological testing — definition and scope

DefinitionFormal psychological testing refers to comprehensive assessments beyond brief screening measures and inventories; it is distinct from routine screening and requires use of the requisite testing authorization forms.

Pre-authorization expectationOther than in exceptional cases, the psychologist should complete a diagnostic interview and relevant screening measures prior to submitting requests for psychological testing authorization.

Not for routine screeningFormal psychological testing is not clinically indicated for routine screening or for administration of brief behavior screening measures and inventories.

Scope of this formThis authorization form is specific to autism spectrum disorder (ASD) testing requests; psychological or neuropsychological testing must be requested on their requisite forms when appropriate.

Non-covered contextsRequests for placement purposes, disability evaluations, forensic purposes, and educational testing/assessment of learning disabilities are excluded from coverage and should be routed elsewhere (e.g., public school system for educational assessments).

OpenPayer

Request for Authorization: Autism Spectrum Disorder Testing (California Medi‑Cal Managed Care)

Coverage Criteria for ASD Psychological Testing

CPT / Billing Codes and Unit Limits

Provider Requirements, Prior Authorization, and Documentation

Background and Rationale

Key Definitions

Related Treatment Modalities