CurrentAnthemPolicy N/A

Psychological Testing Authorization (Maine / Medicare Advantage)

Form and requirements for requesting authorization of formal psychological testing from Anthem (Maine / Medicare Advantage). It explains when testing is appropriate, documentation to submit, and lists billable test CPT codes to request prior to rendering services.

Policy Summary

PayerAnthem

PolicyPsychological Testing Authorization (Maine / Medicare Advantage)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization form listing CPT codes/units and specify tests, versions or subtests with supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

96130-96139CPT codes listed on request form

1Single-unit limit (select codes)

MaineState referenced

Medicare AdvantageProduct referenced

Coverage and Medical Necessity Criteria

Related Billing Codes

CPT-96138-TECHNICIAN-TEST-ADMINISTRATION-SCORING-30-MINUTES

CPT 96138: Technician Administration and Scoring of Multiple Tests, First 30 Minutes

96137-PSYCHOLOGICAL-OR-NEUROPSYCHOLOGICAL-TEST-ADMINISTRATION-AND

96137 – Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure)

CPT-96130-PSYCHOLOGICAL-TESTING-INTERPRETATION-TREATMENT-PLAN-1HR

CPT 96130: Psychological Testing, Interpretation and Treatment Planning (First Hour)

CPT-96139-TECHNICIAN-TEST-ADMINISTRATION-SCORING-ADDITIONAL-30-MINUTES

CPT 96139: Technician Administering and Scoring Tests, Additional 30 Minutes

CPT-96136-PSYCHOLOGICAL-NEUROPSYCHOLOGICAL-TEST-ADMINISTRATION-FIRST-30-MINUTES

CPT 96136: Psychological/Neuropsychological Test Administration and Scoring, First 30 Minutes

CPT-96131-PSYCHOLOGICAL-TESTING-ADDITIONAL-HOUR

CPT 96131: Psychological Testing, Each Additional Hour

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Pre-assessment completed: A diagnostic interview and relevant screening measures/brief inventories have been completed prior to submitting the testing request.

Screeners and brief inventories are expected as part of routine assessment.

Documentation provided: Include clinical/medical records, date of diagnostic interview, results of screening measures, treatment history, and specific rationale explaining what questions cannot be answered without testing.

Explain how results will impact the course of treatment.

Appropriate use: Testing requested is for clinical diagnostic or treatment-planning purposes; requests for placement, disability evaluations, forensic purposes, or educational testing/assessments for learning disabilities are not covered through this form.

Autism and neuropsychological testing and other special-purpose testing require their specific forms and are not to be requested on this form.

CPT and test details: The request must specify which psychological CPT codes and units are requested and specify test names/versions or selected subtests to be administered; observe single-unit limits where noted.

Codes 96130, 96136, and 96138 are listed as 'Only one unit allowed' on the request form.

Provider Steps, Authorization & Documentation Requirements

Prior Authorization

Authorization must specify CPT codes, units, and test details

Prior authorization must list each psychological CPT code and the number of units requested, and specify the test names, versions, or selected subtests to be administered. Note that codes 96130, 96136, and 96138 are annotated on the form as 'Only one unit allowed.'

List each CPT code and Unit(s) requested on the prior authorization form.
Specify test names, versions, or which subtests will be administered for each code.
Observe single-unit limits for 96130, 96136, and 96138 as indicated on the form.

Step Therapy

Complete diagnostic interview and screening measures before authorization

A diagnostic interview and relevant screening measures/brief inventories must be completed prior to submitting the testing authorization; brief screeners and inventories are expected as part of a routine diagnostic assessment.

Complete a diagnostic interview and any relevant brief screening measures before requesting authorization.
Document which brief inventories or screening measures were used as part of the assessment.

Documentation Required

Attach clinical records, interview date, screening results, treatment history, and rationale

Include supporting clinical/medical records with the request: date of the diagnostic interview, results of screening measures, treatment history, rationale for testing (what questions cannot be answered by interview/records/screeners), and explanation of how test results will affect treatment.

Attach relevant clinical and medical records and diagnostic assessments.
Provide the date of the diagnostic interview and results of any screening measures administered.
Describe prior treatment history and a clear rationale explaining why testing is needed and how results will impact care.

Denial Risk

Requests for placement, disability, forensic, educational, autism/neuro testing are not covered here

Do not use this authorization form to request testing for placement, disability evaluations, forensic purposes, educational testing for learning disabilities, or autism/neuropsychological testing — those are not covered here and require their specific processes or referrals.

Placement, disability, and forensic testing requests are not covered benefits on this form.
Educational testing for learning disabilities should be referred to the public school system.
Autism and neuropsychological testing require their specific forms and are not to be submitted via this process.

Definitions and Test Scope

Formal psychological testing — definition and distinctions

DefinitionComprehensive, standardized psychological assessments that require specific CPT billing codes (e.g., 96130, 96131, 96136, 96137, 96138, 96139) and separate prior authorization; these are distinct from brief screening measures and inventories completed as part of a routine diagnostic interview.

What is NOT includedBrief screeners and brief behavior inventories used during the diagnostic interview are expected as routine assessment and do not require authorization on this form.

Authorization requirementRequests for formal psychological testing must specify CPT codes, units, and the specific tests/versions or subtests to be administered; select codes (96130, 96136, 96138) allow only one unit per request.

Clinical prerequisitesA diagnostic interview and relevant screening measures/brief inventories should be completed by the psychologist prior to submitting a testing authorization request.

Excluded purposesTesting requested for placement, disability evaluations, forensic purposes, or educational assessments (learning disabilities) are not covered on this form and should be handled via the appropriate process or agency.

OpenPayer

Psychological Testing Authorization (Maine / Medicare Advantage)

Coverage and Medical Necessity Criteria

Related Billing Codes

Billable CPT Codes for Psychological Testing

Provider Steps, Authorization & Documentation Requirements

Background and Rationale

Definitions and Test Scope

96130	Psychological testing evaluation services (Only one unit allowed)
96131	Psychological testing evaluation services (per form listing)
96136	Psychological testing administration/scoring (Only one unit allowed)
96137	Psychological testing administration/scoring (add-on listed)
96138	Psychological testing report/interpretation (Only one unit allowed)
96139	Psychological testing report/interpretation (add-on listed)