Autism Spectrum Disorder (ASD) psychological testing requests
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Maine policy alerts
Know when Blue Cross Blue Shield - Maine releases new policies or updates existing guidance.
Monitor payer policy activity
Form and policy governing prior authorization requests for formal psychological testing for ASD for members served by the payer; describes required clinical information, screening measures, and requested CPT codes. Affects providers submitting ASD testing requests.
No material clinical or coverage changes in this revision.
Authorization and Medical Necessity Criteria
inv-01: Authorization/Medical Necessity Criteria for ASD Testing
Covered when ALL of the following are met
Form includes checklist of assessments to indicate completion (see Clinical assessment).
List of screeners provided on form; screener results field required.
Rationale for testing section includes question about ABA access (Yes/No).
Treatment history section and fields for prior testing dates/results are present on the form.
Submission instructions and CPT code/unit fields are on the form; prior authorization must be obtained before services are rendered.
Requests submitted for placement purposes, disability evaluations, and forensic purposes are not covered benefits. The form and policy apply only to Autism Spectrum Disorder testing requests; requests for educational testing or assessment of learning disabilities should be referred to the public school system. Use the appropriate psychological or neuropsychological testing forms for any non‑ASD testing requests.
Per the policy, formal psychological testing is not clinically indicated for routine screening or for the administration of brief behavior screening measures and inventories. Such screeners are considered an expected part of the routine diagnostic process and, except in exceptional cases, a psychologist should complete a diagnostic interview and relevant screening measures prior to submitting a request for formal testing.
Billing Codes and Unit Limits
| 96130 | Psychological testing evaluation services (one unit maximum) |
| 96131 | Psychological testing evaluation services |
| 96136 | Psychological test administration and scoring (one unit maximum) |
| 96137 | Psychological test administration and scoring |
| 96138 | Psychological or neuropsychological test administration (one unit maximum) |
| 96139 | Psychological or neuropsychological test administration |
Prior Authorization & Documentation Requirements
Prior authorization required — submit form with CPT codes/units before services
Submit prior authorization using the Autism Spectrum Disorder testing request form via Availity Essentials (https://Availity.com) or the provider link at https://anthem.com/in/provider, or fax the completed form to 844-456-2698 before services are rendered. The submission must list the CPT code(s) and total units requested (e.g., 96130, 96131, 96136, 96137, 96138, 96139).
- Form must be submitted prior to rendering services.
- Include requested CPT code(s) and total units on the form.
If requesting testing for ABA access, mark checkbox and provide rationale
Indicate on the form whether the testing request is to access Applied Behavior Analysis (ABA) services and provide the rationale when ABA access is sought.
- Checkbox on the Rationale for testing section requires Yes/No selection for ABA access.
- If Yes, include rationale for testing to support ABA access.
Required documentation — completed form plus clinical records and screening results
Attach the completed ASD testing request form with supporting clinical and medical records; include the date of the diagnostic interview, results of screening measures (e.g., ASRS, SCQ, SRS, MCHAT, CARS, GARS, GADS), treatment history, rationale for testing, and the specific CPT codes and units requested.
- List which clinical assessments were completed and the date of the diagnostic interview.
- Provide screener names and results.
- Document treatment history, how results will affect treatment, and the CPT codes/units requested.
Non‑covered purposes that may trigger denial
Requests submitted for placement purposes, disability evaluations, educational testing, or forensic purposes are not covered benefits and may be denied; educational testing/learning disability assessments should be referred to the public school system.
- Non-covered purposes include placement, disability evaluations, and forensic evaluations.
- Refer educational testing or assessment of learning disabilities to the public school system.
Clinical Context
Background: Formal psychological testing is reserved for situations where information from a diagnostic interview, collateral history, record review, direct observation, and relevant screening instruments does not fully address the diagnostic or treatment questions. The policy emphasizes that a diagnostic interview and relevant screening measures should be completed and documented before requesting testing, and that brief screening instruments and inventories are components of the standard diagnostic process rather than indications for standalone formal testing.
Non-covered Purposes
ABA Access Indication
inv-12: ABA access indication
Checkbox present on Rationale for testing section.
Behavioral and Developmental Evaluations
inv-13: Behavioral/Developmental evaluations
Several checklist items and fields in Treatment history section; prior testing fields present.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.