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    v1.0.28
    OpenPayerPolicy UpdatesPediatrics/NeonatologyBCBS Vermont ASD Screening Coverage | OpenPayer
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    CurrentBlue Cross Blue Shield of VermontPolicy 3.01.VT203

    Pediatric Neurodevelopmental and Autism Spectrum Disorder (ASD) Screening Corporate Medical Policy

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    Coverage, prior authorization, documentation, and coding requirements for standardized developmental and autism spectrum disorder screening in pediatric patients; intensive developmental evaluation is outside this policy’s scope.

    Policy Summary
    PayerBlue Cross Blue Shield of Vermont
    PolicyPediatric Neurodevelopmental and Autism Spectrum Disorder (ASD) Screening
    Policy CodePolicy 3.01.VT203
    Change TypeMaterial revision
    Effective DateOct 1, 2025
    Last ReviewJul 1, 2025
    Next Review DateJun 1, 2026
    Key ActionObtain prior authorization when developmental or autism screening exceeds five tests.
    SourceLink
    POLICY UPDATE CHANGES

    Removed the prior approval requirement based solely on testing children older than 5 years and removed the upper age limit for testing.

    Prior authorization is required when the number of screening tests exceeds five.

    5Screening tests without prior authorization
    9, 18, 30 moDevelopmental screening ages
    18, 24 moAutism screening ages

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    96110, 96112, 96113
    CPT codes addressed
    >5 testsPrior authorization threshold

    Coverage Criteria

    Standardized developmental and ASD screening

    Screening may be considered medically necessary and covered when ALL of the following are met:

    Covered screening

    • Standardized screening service

      • ONE or more accepted standardized tools

        • The service uses an established standardized developmental or autism screening instrument, such as the Ages and Stages Questionnaires (ASQ-3), Battelle Developmental Inventory Screening (BDI-2 or BDI-3), Bayley Infant Neurodevelopmental Screen (BINS), Child Development Inventory (CDI), Parent's Evaluation of Developmental Status (PEDS), or Modified Checklist for Autism in Toddlers (M-CHAT or M-CHAT-R/F).
      • The screening includes scoring, interpretation, and a report or other required documentation.

    • Service scope

      • The service is screening only and is not an intensive developmental or neurodevelopmental evaluation.

        More intensive evaluation, with or without referral to another practitioner, may require separate prior authorization.

    Screening within five-test allowance

    Screening codes do not require prior authorization when the service is within the five-test allowance. Covered screening must still meet the applicable standardized-testing and documentation requirements.

    Within the authorization allowance

    • The screening service is among the first five screening tests.<=5 screening tests

      CPT 96110 is accepted five times from pediatricians and family practice practitioners without prior authorization.

    Intensive developmental or neurodevelopmental evaluation is outside the scope of this screening policy. This policy addresses standardized pediatric developmental and autism spectrum disorder screening only; more intensive evaluation may require separate authorization under the applicable testing policy.

    Pediatric neurodevelopmental and autism spectrum disorder screening is not medically necessary when the number of screening tests exceeds five. Screening beyond this threshold requires the applicable prior authorization.

    Pediatric neurodevelopmental and autism spectrum disorder screening is not medically necessary when required documentation is not submitted and prior authorization is not obtained when necessary. Providers must document the standardized screening service and obtain authorization when the applicable requirements are triggered.

    Coding and Screening Schedules

    Developmental ScreeningCPTCovered
    96110Developmental screening (e.g., developmental milestone survey, speech, and language delay screen), with scoring and documentation, per standardized instrument
    Developmental Test Administration and InterpretationCPTCovered
    96112Developmental test administration (including assessment of motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour
    96113Developmental test administration (including assessment of motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; each additional 30 minutes
    Number of screening tests
    ThresholdMore than five screening tests triggers the prior authorization requirement.
    Within allowanceScreening does not require prior authorization when the number of tests is five or fewer.
    Applicable CPT codesThe greater-than-five threshold applies to CPT 96110, 96112, and 96113.
    Developmental screening age schedule
    9 monthsRecommended developmental screening age.
    18 monthsRecommended developmental screening age.

    Provider and Authorization Actions

    Note

    Use the five-test CPT 96110 allowance

    The Plan accepts CPT 96110 five times from pediatricians and family practice practitioners without prior authorization.

    Prior Authorization

    Obtain authorization after five screening tests

    Prior authorization is not required unless the number of screening tests exceeds five. When screening exceeds five tests, prior authorization is required for CPT 96110, 96112, and 96113.

    Prior Authorization

    Authorize intensive evaluation when required

    More intensive developmental or autism spectrum disorder evaluation, with or without referral to another practitioner, may require prior authorization for additional testing. Refer to the applicable Neuropsychological and Psychological Testing policy.

    Clinical Background

    The policy reflects EPSDT recommendations for developmental screening at 9, 18, and 30 months and autism screening at 18 and 24 months; screening may also be appropriate beyond these ages. Covered screening must use standardized, established instruments with scoring, interpretation, and reporting, and is more comprehensive than an informal developmental survey. This policy addresses screening only, not intensive developmental or neurodevelopmental evaluation.

    Key Definitions

    Pediatric neurodevelopmental and ASD screening
    Standardized testingUses an established standardized screening instrument, such as the Ages and Stages evaluation, rather than an informal developmental survey.
    Scoring and interpretationIncludes scoring and interpretation of the standardized screening results.
    Reporting and documentationIncludes a report or documentation of the screening service; the clinical note must identify one or more screening tools used.
    Intensive developmental or ASD evaluation
    ScopeAn evaluation more intensive than standardized screening.
    Additional testing or referralMay involve additional testing or referral to another practitioner.
    Policy Summary
    PayerBlue Cross Blue Shield of Vermont
    PolicyPediatric Neurodevelopmental and Autism Spectrum Disorder (ASD) Screening
    Policy CodePolicy 3.01.VT203
    Change TypeMaterial revision
    Effective DateOct 1, 2025
    Last ReviewJul 1, 2025
    Next Review DateJun 1, 2026
    Key ActionObtain prior authorization when developmental or autism screening exceeds five tests.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Screening SchedulesProvider and Authorization ActionsClinical BackgroundKey Definitions
    30 months
    Recommended developmental screening age.
    Autism screening age schedule
    18 monthsRecommended autism screening age.
    24 monthsRecommended autism screening age.
    Beyond recommended agesScreening may be appropriate beyond these ages.
    Documentation Required

    Name the standardized screening tool

    Clinical notes must identify one or more standardized, established developmental or autism screening tools used for the service.

    • Examples include ASQ-3, BDI-2 or BDI-3, BINS, CDI, PEDS, and M-CHAT or M-CHAT-R/F.
    Documentation Required

    Submit records for additional screening

    When additional screening involving more than five visits using CPT 96110 is required, the requesting provider must submit the screening tests already completed and the rationale for additional testing.

    • Submit the screening tests already completed.
    • Submit the rationale for additional testing.
    Documentation Required

    Document the test even without a specific diagnosis

    For additional CPT 96110 screening, no specific diagnosis is required, but a standardized screening test must be documented in the visit note.

    • Document the standardized screening test in the visit note.
    • No specific diagnosis is required for the additional CPT 96110 screening.
    Denial Risk

    Avoid denial for unauthorized additional testing

    Screening is not medically necessary when the number of screening tests exceeds five without the required prior authorization, or when required documentation is not submitted and prior authorization is not obtained when necessary.

    Denial Risk

    Do not use the screening policy for intensive evaluation

    This policy addresses screening only, not intensive developmental or neurodevelopmental evaluation. More intensive evaluation may require prior authorization under the applicable Neuropsychological and Psychological Testing policy.

    Prior authorizationMay require prior authorization for additional testing under the applicable testing policy.