CurrentAnthem Blue CrossPolicy N/A

Request for Authorization: Psychological Testing

A submission form and instructions for requesting prior authorization of formal psychological testing for Anthem Blue Cross Medi-Cal Managed Care (California). It outlines required clinical information, screening prerequisites, requested CPT codes/units, and submission methods. It excludes neuropsychological/autism testing and non-covered purposes (placement, disability, forensic, educational testing).

Policy Summary

PayerAnthem Blue Cross

PolicyRequest for Authorization: Psychological Testing

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionSubmit the authorization form with required clinical documentation and specified CPT codes/units (electronically via Availity or fax to 855-473-7902) prior to rendering psychological testing.

POLICY UPDATE CHANGES

No material clinical or coverage changes identified in this brief.

6CPT codes listed

4Excluded request purposes

2Submission methods

Policy overview

This form standardizes prior authorization requests for formal psychological testing for Anthem Blue Cross Medi-Cal Managed Care. It applies to psychological testing CPT codes listed on the form and is intended for use prior to rendering testing services. The form specifies that it is for psychological testing only and that requests for neuropsychological or autism testing must be completed on their separate requisite forms. Submit the authorization form electronically via https://Availity.com or fax to 855-473-7902.

Preauthorization submission requirements & exclusions

Exclusions / Not covered request purposes

Requests for formal psychological testing should include ALL of the following:

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Specialty test routing

Requests for the following purposes are not covered:

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CPT codes on form

Psychological testing CPT codes listed on formCPT

96130	Psychological testing evaluation services (Only one unit allowed) - listed as option
96131	Psychological testing evaluation services - listed as option
96136	Psychological or neuropsychological test administration and scoring (Only one unit allowed) - listed as option
96137	Psychological or neuropsychological test administration and scoring - listed as option
96138	Psychological or neuropsychological test interpretation (Only one unit allowed) - listed as option
96139	Psychological or neuropsychological test interpretation - listed as option

The form explicitly annotates certain CPT codes as Only one unit allowed (specifically 96130, 96136, and 96138); providers must respect these unit limits when requesting authorization.

What providers must do

Prior Authorization

Submit authorization request before rendering services

Submit the completed authorization form with all required clinical documentation and specified CPT codes/units before providing psychological testing services. Send the form via the preferred electronic method (Availity) or by fax. Ensure the submission occurs prior to rendering services.

Availity (preferred electronic submission)
Fax: 855-473-7902

Documentation Required

Provide supporting clinical documentation

Include complete supporting clinical documentation with the authorization request: provide the date of the diagnostic interview and any relevant clinical/medical records; list screening measures administered and pertinent results; detail treatment history (therapy, medication management, school-based services, other services with frequency, duration, current status, and response); state the rationale for testing explaining questions not resolved by interview/records/screeners and how results will impact treatment; and attach relevant medical records and diagnostic assessments.

Date of diagnostic interview
Screening measures administered and results
Treatment history (frequency, duration, current status, response)
Rationale for testing
Attachments: relevant medical/diagnostic records

Billing Rule

Unit limits indicated on form

The form notes unit limits for certain CPT codes. Providers must respect these limits when requesting authorization—the form indicates that only one unit is allowed for specific codes.

96130
96136
96138

Denial Risk

Risk of non-coverage for excluded purposes

Requests for certain purposes are not covered benefits and are likely to be denied or should be referred. Do not use this form for placement decisions, disability evaluations, forensic purposes, or educational testing for learning disabilities (refer educational testing to the public school system).

Requests for placement purposes
Disability evaluations
Forensic purposes
Educational testing or educational assessment for learning disabilities (refer to public school system)

Background & definitions

Routine screening measures and a diagnostic interview should be completed by the psychologist prior to submitting requests for formal testing; routine brief screening/assessment is not an indication for formal testing except in exceptional cases. The form clarifies that requests for placement, disability evaluations, forensic purposes, or educational testing for learning disabilities are not covered and should be routed appropriately (e.g., educational assessment to the public school system). Specialty tests such as neuropsychological or autism testing require completion on their respective forms rather than this psychological testing form.

Definitions

TermPsychological testing

DefinitionFormal testing services identified by CPT codes 96130, 96131, 96136, 96137, 96138, 96139; this form is for psychological testing only (not neuropsychological or autism testing).

Document revision history

Current version — no dated revisions providedstatusLatest

Form is CURRENT. It standardizes prior authorization for psychological testing (CPT codes 96130, 96131, 96136, 96137, 96138, 96139), specifies that diagnostic interview and screening measures should precede testing, notes unit limits for certain CPT codes (only one unit allowed for 96130, 96136, 96138), excludes neuropsychological/autism forms and non-covered purposes (placement, disability, forensic, educational testing), and provides submission methods (Availity or fax 855-473-7902).