CurrentAnthemPolicy N/A

Request for Authorization: Psychological Testing (New York Medicaid)

Form and requirements for requesting authorization of formal psychological testing for New York Medicaid members covered by Anthem; specifies required supporting information, excluded request types, and CPT codes for billing. Affects providers submitting requests for psychological testing.

Policy Summary

PayerAnthem

PolicyPsychological testing authorization (New York Medicaid)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed authorization form with diagnostic interview date, screening results, test specifications, and supporting records via Availity or fax to 844-452-8072.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

96130-96139CPT codes listed for psychological testing/evaluation

New YorkState-specific form jurisdiction

Fax: 844-452-8072Alternate submission method

Placement/Disability/Forensic/EducationalRequest types not covered

Coverage Criteria

Initial authorization criteria

Authorization supported when ALL of the following are met

Pre-evaluation requirements: A diagnostic interview and relevant screening measures/brief inventories must have been completed and documented prior to requesting formal psychological testing; screening results should be provided.

Include date of diagnostic interview and specify which screening measures were administered and their pertinent results.

Documentation supporting need: Provide clinical presentation and duration of symptoms, treatment history, review of relevant records (medical, academic/IEP), prior screening measures and results, and a clear rationale describing what specific clinical questions cannot be answered by interview/records/screeners and how test results will impact treatment.

Attach pertinent clinical/medical records, academic/IEP records when applicable, and indicate how results will change management.

Requests for formal psychological testing for New York Medicaid members are subject to specific exclusions and general coverage criteria. Requests for placement purposes, disability evaluations, and forensic purposes are not covered benefits. Requests for educational testing or educational assessment for learning disabilities should be referred to the public school system. Providers must document the clinical assessment components completed (for example: brief inventories/screening measures, structured developmental/social history, consultations, direct observation, and relevant family history) when submitting requests for testing.

Policy Summary

PayerAnthem

PolicyPsychological testing authorization (New York Medicaid)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed authorization form with diagnostic interview date, screening results, test specifications, and supporting records via Availity or fax to 844-452-8072.

SourceLink

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Formal psychological testing is not indicated for routine screening or for administration of brief behavior screening measures and inventories. Brief screeners and inventories are considered expected components of a standard diagnostic evaluation; therefore, using formal psychological testing solely to perform routine screening will not meet medical necessity. Except in exceptional cases, a diagnostic interview and relevant screening measures should be completed and documented by the psychologist before requesting authorization for formal testing.

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for psychological testing. Submit requests electronically via Availity (https://Availity.com) using the psychological testing authorization form for CPT codes 96130–96139. Electronic submission is preferred; fax submission (844-452-8072) is accepted if necessary. Ensure submission follows Anthem jurisdiction rules and the member’s plan requirements.

Submit authorization before services are rendered
Preferred: Availity portal (https://Availity.com)
Fax (alternative): 844-452-8072
Applicable CPT range: 96130–96139

Documentation Required

Screening and Diagnostic Interview Required

A diagnostic interview and relevant screening measures must be completed by the psychologist prior to submitting a testing authorization request except in exceptional cases. Screening measures and brief inventories (for example Achenbach, ADHD rating scales, BAI, BASC, CBCL, Conners, MASC, etc.) are considered part of routine diagnostic assessment and do not by themselves justify formal psychological testing.

Complete and document a diagnostic interview date
Administer and document pertinent screening measures and results prior to request
Note duration of symptoms and treatment history in the record

Documentation Required

Required Supporting Documentation

Include the following supporting documentation with the authorization request: clinical/medical records, date of diagnostic interview, results of screening measures, presenting problems and symptoms, duration of symptoms, relevant treatment history (therapy, medication management, school-based services, other services), consultations (physician, school), review of records (medical, academic/IEP), and any other information that supports the rationale for testing.

Clinical/medical records supporting the need for testing
Date of diagnostic interview and who conducted it
Pertinent screening measure names and results
Presenting problems and specific clinical information
Treatment history and response to treatment
Consultation notes and reviews of academic records/IEP

Documentation Required

Test Specification and Administrative Details

Specify exact tests, versions, and subtests to be administered, total units and total time requested, and the CPT codes being requested (96130–96139). For each CPT code indicate units requested and list the evaluation services/test names. Provide the provider signature, credential (current or provisional), provider and billing facility NPI/Tax ID, contact information, and servicing address. If subtests are selected, identify them. Attach any separate sheet if necessary.

List each test name and version (or selected subtests)
Indicate CPT code(s) and units requested (96130–96139) and total time
Provide provider signature and credential (current or provisional)
Include provider and billing facility NPI and Tax ID, phone, fax, and email
Attach additional sheets for long test lists if needed

Coding

Covered CPT Codes (form request)CPTCovered

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

Psychological Testing Modalities

Visit Limits & Unit Rules

Specified CPT codes (single-unit notes)

96130Psychological testing evaluation services (form lists as 'Only one unit allowed')

96131Psychological testing evaluation services (listed on form)

96136Psychological or neuropsychological test administration (form lists as 'Only one unit allowed')

96137Psychological or neuropsychological test administration (listed on form)

96138Psychological or neuropsychological test administration (form lists as 'Only one unit allowed')

96139Psychological or neuropsychological test administration (listed on form)

Definitions & Rationale

Rationale for testing — required content

Clinical questions requiring formal testingQuestions that cannot be resolved by diagnostic interview, review of records, or screening measures — i.e., issues remaining after a complete diagnostic interview and relevant brief inventories — should be specified in the rationale.

Prior evaluations that are insufficientRoutine screening measures and brief behavior screening inventories are considered part of standard diagnostic evaluation and do not alone justify formal psychological testing.

Required documentation of screeningProvide dates and results of prior screening measures, summary of the diagnostic interview, and review of pertinent records (medical, academic/IEP) to show why testing is needed.

Impact on treatmentRationale must state how testing results will change or guide the course of treatment (for example, clarifying diagnosis, informing treatment selection, or guiding interventions).

Background

The purpose of formal psychological testing is to address specific clinical questions that cannot be resolved through the diagnostic interview, records review, or routine screening measures. Testing is intended to provide standardized, instrument-based data to clarify diagnosis, characterize symptom patterns, assess cognitive or neuropsychological functioning, or inform individualized treatment planning. Before testing is requested, providers should complete a diagnostic interview and relevant screening measures and document why those methods alone cannot answer the clinical question or guide treatment decisions.