Neuropsychological Testing Authorization
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This document governs prior authorization and request procedures for neuropsychological (psychometric) testing for Anthem/Blue Cross Blue Shield members in Maine, including clinical indications and required supporting information for providers submitting requests.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity
Medical Necessity Criteria
Covered when ALL of the following are met
Repeat testing to track status or recovery is subject to individual consideration and is generally not warranted.
Provider should document the applicable indication(s) and relevant dates on the request form.
Routine repeat neuropsychological testing to track the status of an illness or progress of recovery is generally not warranted and will be considered on an individual case basis. Testing is considered medically necessary only when there is evidence that the results will have a timely and direct impact on the member's treatment plan for the specified clinical indications.
Authorization for routine outpatient care is not required for network providers treating eligible members. However, authorization for neuropsychological testing remains subject to verification of member eligibility and is not a guarantee of payment. Requests that are incomplete or illegible cannot be processed and may lead to denial.
Codes and Internal Hour Fields
| 96116 | Hours (internal use on form) |
| 96119 | Hours (internal use on form) |
| 96118 | Hours (internal use on form) |
Provider Submission Requirements and Actions
Prior authorization submission and codes
Submit prior authorization requests electronically via Availity (https://availity.com). Requests may also be faxed to 844-430-1703. Include the completed Request for Authorization form and all required clinical documentation listed below. Use applicable procedure and diagnosis codes on the request.
- Preferred submission: Availity (https://availity.com)
- Fax: 844-430-1703
- Include applicable procedure and diagnosis codes on the request
Provider responsibilities
Complete all provider action fields on the authorization request and supply any additional information requested during review in a timely manner to avoid delays.
- Provide source of referral, provider specialty, address, and phone
- Ensure all referral and clinical assessment fields are completed
Required clinical documentation
Include comprehensive clinical documentation to support medical necessity: relevant medical records, clinical interview/psychiatric evaluation, developmental/psychosocial history, neurologic exam, EEG/neuroimaging results, prior testing reports, medication/substance abuse history, and consultations (PCP, school, family, specialists).
- Medical records supporting the indication (e.g., TBI, stroke, dementia, encephalitis)
- Clinical interview and psychiatric evaluation dates
- Prior neuropsychological testing reports (if any)
- Neuroimaging (CT, MRI, PET) and EEG results
- Documentation of medication and substance use evaluations
Eligibility and completeness
Authorization is subject to verification of member eligibility and benefits at the time of request and is not a guarantee of payment. Incomplete or illegible requests cannot be processed. Routine outpatient care authorization may not be required for in-network providers; confirm requirements for neuropsychological testing prior to delivery of services.
- Authorization contingent on member eligibility verification
- Incomplete or illegible requests will be returned and delay processing
- Network providers may have different routine authorization requirements — verify before care
Background
Neuropsychological testing, also called psychometric testing, is a comprehensive evaluation of cognitive, motor, and behavioral functional abilities related to developmental, degenerative, and acquired brain disorders. It is intended to augment medical history, physical examination, and neurological investigations. Use of testing should be driven by specific clinical questions where results will meaningfully and promptly affect treatment decisions.
Definitions
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