Behavioral health psychological and neuropsychological assessment supplemental form coverage criteria
A supplemental form to collect clinically relevant, administrative, diagnostic, and coding information when requesting psychological or neuropsychological testing services under Carelon Behavioral Health; used by clinicians and facilities to support medical necessity determinations for health plan review.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Medical necessity supportive criteria
Assessment is supported when documentation demonstrates the following clinical needs and contextual information.
See checklist options on form.
Form asks date of last assessment and reasons if testing occurred in past year.
Form provides fields for CPT codes/units, list of likely tests, and checkboxes for time-increasing factors.
Form includes substance use and medication effect questions and related follow-up fields.
The form explicitly asks whether units requested are being used primarily to determine special education needs or to answer legal questions under a court order. These purposes are captured with discrete checkboxes and should be identified on the request because they may affect coverage determinations. Providers must therefore indicate if units are for special education or if units are to answer questions of law (court-ordered) when submitting the supplemental form.
The form asks whether a standard clinical evaluation was completed in the past 12 months and, if so, to document when and by whom. It further requests an explanation of why a standard clinical evaluation cannot answer the assessment questions if one exists. This language indicates that testing may be inappropriate when recent standard clinical evaluation adequately addresses the clinical questions—providers should document why testing is necessary now if a standard evaluation within the prior 12 months exists.
CPT Codes and Units
| 96130 | Psychological testing evaluation services, first hour |
| 96131 | Psychological testing evaluation services, each additional hour |
| 96132 | Neuropsychological testing evaluation service, first hour |
| 96133 | Neuropsychological testing evaluation service, each additional hour |
| 96146 | Automated neurobehavioral testing |
| 96136 | Test administration by professional, first 30 minutes |
| 96137 | Test administration by professional, each additional 30 minutes |
| 96138 | Test administration by technician, first 30 minutes |
| 96139 | Test administration by technician, each additional 30 minutes |
| 96116 | Neurobehavioral status exam, first hour |
Provider Submission and Documentation Requirements
Specify CPT codes & units
Prior authorization/authorization requests must specify all CPT codes and the exact number of units requested for each psychological and neuropsychological testing code. Include the rationale for the number of units and how test duration/complexity justifies the request.
- Specify CPT codes (e.g., 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96116, 96121, 96146) and the number of units for each code.
- Enter the number of units requested and list likely tests to be administered.
- Provide clear justification when more time is needed due to factors such as depressed mood, medical/neurological conditions, processing speed deficits, receptive communication difficulties, grapho-motor deficits, performance anxiety, or other specified reasons.
Required documentation
Submit a completed form that includes identifying information, relevant diagnostic data, assessment plan and history, and the CPT codes with units requested. Ensure supporting documentation (clinical evaluation results, imaging, prior testing dates, and explanation of why testing is necessary now) accompanies the request.
- Attach recent standard clinical evaluation if available (within 12 months) or explain why one cannot answer assessment questions.
- Document prior testing history and reasons why additional testing is required (e.g., unexpected symptom change, invalid prior testing, evaluate treatment response).
- Indicate whether units are requested to differentiate medical/psychiatric conditions, for educational placement, or for legal/court-ordered evaluations.
Incomplete coding/justification risk
Incomplete or missing CPT codes, unspecified unit counts, or lack of clinical justification for the units requested may result in claim denial or delay. Ensure all fields on the supplemental form are completed and provide explicit rationale tying number of units to clinical complexity or testing needs.
- Omitting unit counts for listed CPT codes risks automatic denial.
- Vague or absent justification for additional time (units) may be considered not medically necessary.
- Incomplete identifying or diagnostic information (dates of service, DOB, provider TIN/NPI, primary diagnosis) can delay authorization decisions.
Actionable provider requirements
Providers must include a clear action note on the form: list the likely tests, state specific factors that increase time requirements, and sign/date the request. Requests lacking this actionable information are at higher risk for denial.
- List likely tests to be administered and number of units per CPT code.
- State specific factors that may require more time (select from provided checklist and add details as needed).
- Requesting clinician signature and date are required.
Background and Purpose
Psychological and neuropsychological assessments are intended to clarify diagnosis, quantify severity, and determine functional impact. The supplemental form prompts clinicians to document current symptoms and functional impairments, prior testing (including date or indicate “no prior testing”), reasons testing is necessary now (for example, unexpected change in symptoms, prior invalid testing, or to evaluate treatment response), and whether assessment is needed to assess function. These elements support use of testing to contribute to differential diagnosis, inform or reformulate treatment planning, evaluate treatment response, and determine the clinical and functional significance of cognitive or behavioral findings.
Key Definitions
Service Limits and Unit Guidance
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