Authorization and Coverage Requirements for Formal Psychological Testing
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This document governs prior authorization and clinical submission requirements for formal psychological testing requests for Blue Cross Blue Shield - Maine members; it affects psychologists and other providers requesting coverage for psychological testing. It excludes requests for placement, forensic, and educational testing for school purposes.
No material clinical or coverage changes in this revision.
Coverage Criteria for Psychological Testing
Medical necessity criteria
Covered when ALL of the following are met
See authorization prior_auth and submission fields
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Requests for psychological testing for placement or forensic purposes are not covered benefits. Requests for educational testing and assessment of learning disabilities that are for educational purposes should be referred to the public school system rather than submitted for coverage under this policy.
Formal psychological testing is not clinically indicated for routine screening or for the administration of brief behavior rating scales and inventories. Brief rating scales and inventories are considered part of a routine, complete diagnostic process and do not by themselves justify formal testing.
Provider Requirements and Submission Instructions
Prior authorization required
Prior authorization must be requested before psychological testing is performed; submit electronically using the preferred method at https://www.availity.com or via fax to 844-430-1703 and include the tests and units requested along with supporting clinical information.
- Request prior authorization before testing is performed
- Preferred electronic submission via Availity; fax alternative 844-430-1703
- Include test names, units requested, and supporting clinical information
Assessment prerequisites before submission
Complete a diagnostic interview and administer all relevant rating scales prior to submitting a testing authorization request except in exceptional cases; formal testing is reserved for questions not answerable by interview and scales.
- Diagnostic interview and relevant rating scales expected before submission
- Formal psychological testing is not indicated for routine screening or brief inventories
Required documentation for authorization
Submit documentation that demonstrates medical necessity: completed clinical assessment items, treatment history and dates, date of diagnostic interview, rating scale results, prior testing history and the rationale for testing including current questions to be answered and how results will impact treatment.
- Clinical interview, family/academic records review, medical/psychiatric history
- Date of diagnostic interview and results of rating scales
- Treatment history (frequency, duration, current status) and previous testing details
- Rationale describing why testing is needed and how results will change treatment
- List of tests/services and units requested
Non-covered request types
Do not submit requests for placement or forensic purposes (these are not covered); educational testing and assessment of learning disabilities for educational purposes should be referred to the public school system.
- Placement and forensic testing requests are non-covered benefits
- Educational testing/learning-disability assessments for school purposes should be referred to the public school system
Background and Rationale
Formal psychological testing is intended for situations where the diagnostic interview, review of records, and relevant rating scales do not adequately answer the clinical question. Except in exceptional cases, a diagnostic interview and all relevant rating scales should be completed by the psychologist prior to requesting authorization for formal testing so that testing is reserved for questions that cannot be resolved through interview and scales alone.
Definitions
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