CurrentAnthemPolicy N/A

Request for Authorization: Psychological Testing (Indiana)

Form and guidelines for requesting prior authorization of psychological testing for Anthem members in Indiana programs (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, Indiana PathWays for Aging, and Medicare Advantage). Specifies required documentation, exclusions, and the CPT codes billed for psychological testing.

Policy Summary

PayerAnthem

PolicyRequest for Authorization: Psychological Testing (Indiana)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests for psychological testing (CPT 96130–96139) via Availity or fax with required documentation including diagnostic interview date, screening results, prior testing history, and rationale.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

96130-96139CPT codes listed for psychological testing

IndianaState-specific form/programs

Availity or faxSubmission methods

Placement/Disability/ForensicNon-covered request types

Coverage Criteria

Policy Summary

PayerAnthem

PolicyRequest for Authorization: Psychological Testing (Indiana)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Authorization criteria (clinical and documentation requirements)

Covered when ALL of the following are met

Pre-assessment completed: A diagnostic interview and relevant screening measures/inventories have been completed by the psychologist prior to requesting testing

Formal psychological testing is not indicated for routine screening; screening measures are expected as part of a routine diagnostic process

Documentation provided: Clinical/medical records, date of diagnostic interview, results of prior screening measures, treatment history, previous testing history, and a rationale explaining what questions cannot be addressed by interview/review and how results will affect treatment must be attached

Form requests prior testing history, rationale for testing, and pertinent medical/clinical records

Appropriate use: Request is for clinical diagnostic purposes for psychological testing (not for placement, disability, forensic, or educational testing) and the correct testing form is used (neuropsychological or autism testing require their respective forms)

Requests for placement, disability, and forensic purposes are not covered; educational testing should be referred to the public school system

Requests for psychological testing are not a covered benefit when they are for placement purposes, disability evaluations, or forensic purposes. Educational testing or educational assessment for learning disabilities should be referred to the public school system. This form is intended specifically for requests for psychological testing; separate forms exist for neuropsychological or autism testing. Providers must follow their group/ACO/PMG/IPA authorization and claims practices when submitting requests.

Coding

Covered CPT CodesCPTCovered

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

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed CPT codes below. Submit prior authorization requests using the Anthem psychological testing authorization form (or via the fax numbers provided) before rendering services. Note unit limits where indicated on the form.

Prior authorization is required for CPT codes 96130–96139.
Submit PA using the psychological testing authorization form; fax submission options are available (see form for numbers).
Some codes on the form have unit limitations (e.g., only one unit allowed for certain codes) — ensure requested units comply with the form.

Prior Authorization

Pre-authorization Screening Required

A diagnostic interview and completion of relevant screening measures must be completed prior to submission of a psychological testing authorization request. The form requires the date of the diagnostic interview and documentation of which screening measures were administered and their pertinent results.

Complete a diagnostic interview and record the date on the request form.
Administer and document relevant screening measures (e.g., Achenbach, ADHD rating scales, BAI, BASC, BDI, etc.) prior to submitting the PA.
Include brief inventories, structured developmental/social history, review of records, and any other assessments completed as part of the pre-authorization screening.

Documentation Required

Required Supporting Documentation

Include full supporting documentation when submitting the prior authorization request. Failure to provide required records may delay or result in denial of the request.

Clinical records supporting the request (medical/psychiatric records, clinical interview notes).
Date of the diagnostic interview and details of the clinical assessment performed.
Results of screening measures and brief inventories administered prior to the request.
History of prior testing (dates, results) and rationale for retesting if applicable.
Treatment history, consultation notes (physician, school, other), review of academic records/IEP, and any other pertinent attachments that support medical necessity.

Denial Risk

Non-covered Request Types

Requests for psychological testing that are for placement, disability evaluations, forensic purposes, educational testing/assessment, or other non-covered purposes are not covered benefits and may be denied.

Requests for placement purposes are not covered.
Requests for disability evaluations are not covered.
Forensic evaluation requests are not covered.
Educational testing or assessment for learning disabilities should be referred to the public school system (not covered on this form).

Background

Formal psychological testing is not indicated for routine screening or for administration of brief behavior screening measures and inventories. Screening measures and brief inventories are expected components of a routine diagnostic process. Except in exceptional cases, a diagnostic interview and relevant screening measures should be completed by the psychologist prior to submitting a request for authorization of psychological testing.

Definitions

inv-09: Psychological testing — definition (CPT 96130–96139)

TermPsychological testing

DefinitionEvaluation services using CPT codes 96130–96139 for psychological test administration and scoring as requested on the form

Required pre-assessmentA diagnostic interview and relevant screening measures should be completed by the psychologist prior to requesting testing

Documentation to attachDate of diagnostic interview, results of prior screening measures, prior testing history, clinical/medical records and rationale explaining why testing is needed

Scope noteThis form is for psychological testing requests only; neuropsychological or autism testing require separate forms

Treatment Modalities

Psychological testing (CPT 96130–96139)

Psychological testing CPT codes: Psychological testing services to be authorized correspond to CPT codes 96130–96139. Provider must specify which tests, versions, or subtests will be administered; attach a separate sheet if necessary

Form lists codes 96130–96139 and requests version/subtest information; several codes note 'Only one unit allowed' on the form

Visit Limits and Unit Restrictions

inv-11: Certain listed codes — unit limits

Codes with form note96130, 96136, 96138

Unit limitOnly one unit allowed for the listed codes as indicated on the form

Related administration/scoring codes96131, 96137, 96139 are listed on the form without the 'only one unit allowed' note

Provider actionEnter unit(s) requested and test names/versions; attach separate sheet if administering selected subtests