CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

MA Behavioral Health Neuropsych Testing Form PDF. Opens in a new window

A fillable prior authorization/request form for neuropsychological testing for members across Indiana plans (Anthem/Blue Cross Blue Shield products). It documents clinical indications, required supporting information, requested CPT codes/units, and submission instructions for behavioral health outpatient prior authorization.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyMA Behavioral Health Neuropsych Testing Form PDF. Opens in a new window

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit requests electronically via Availity (preferred) or via fax to the listed behavioral health outpatient fax numbers prior to rendering services; include required supporting documentation to avoid delays.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

6Common CPT codes listed

ConditionalCoverage determination

1Not medically necessary indication (ADHD)

Policy overview

This is a fillable prior authorization/request form for neuropsychological testing used by Anthem/Blue Cross Blue Shield products in Indiana. The form captures member and provider information and documents requested tests and CPT lines/units for processing prior authorization (see CPT code selections and unit fields).

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Medical necessity criteria

Medical necessity guidance

Neuropsychological testing may be considered medically necessary when ALL of the following are met:

ALL of the following

There is a cognitive or behavioral impairment related to a known or suspected medical or neurological condition
Testing will impact medical treatment planning (results must impact treatment planning)
Testing is used to quantify cognitive deficit, monitor change, or differentiate cause
Repeat testing is only medically necessary with supporting medical documentation (routine repeat testing is not generally warranted)

Not considered medically necessary

ANY of the following

Assessment of behavioral disorders including ADHD

Requested clinical indications checklist (examples)

Request form lists the following potential indications (select as applicable) and requires relevant dates and clinical information to support the request:

ANY of the following

Traumatic brain injury (date required)
Encephalitis (date required)
Epilepsy with suspected or documented cognitive impairment
Multiple sclerosis with suspected/demonstrated cognitive impairment (date required)
Anoxic/hypoxic brain injury (date required)

Documentation & submission requirements

Prior Authorization

Submit prior authorization via Availity or fax

Submit prior authorization before rendering neuropsychological testing. Availity is the preferred electronic submission portal; using Availity expedites review. Fax submission is accepted but may delay intake if the form or accompanying documentation is incomplete.

Preferred: Submit prior authorization via Availity (https://availity.com).
Fax intake (may delay processing if incomplete):
BH outpatient (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect): 844-456-2698
BH outpatient (Medicare Advantage): 844-430-1703
BH (Indiana PathWays for Aging): 877-410-0623

Documentation Required

Provide supporting clinical documentation

Provide the following supporting clinical documentation with the prior authorization request. Include dates and copies of reports whenever available.

Comprehensive clinical assessment or consult notes describing cognitive/behavioral symptoms and medical/neurologic history
Neurologic exam documentation (date of exam)
EEG report, if epilepsy or seizure disorder is suspected or relevant (date)
Previous psychological or neuropsychological testing reports (include dates and results)
Medication list (current medications and dates), or mark 'None' if applicable
Substance use history and documentation whether alcohol/illicit substance effects have been ruled out
Rationale for testing: specific questions to be answered and how results will impact treatment
Relevant imaging or surgical history (e.g., intracranial surgery, CVA, anoxic injury) and other pertinent medical records

Documentation Required

Specify ICD-10 diagnosis codes

List all ICD-10 diagnosis codes under evaluation and indicate for each whether the code is current or provisional. Mark each code clearly on the form (e.g., by checking 'Current' or 'Provisional').

Test specification requirements

ALL of the following

List each neuropsychological test requested, including specific version (if applicable).
Indicate which subtests will be administered when only selected subtests are used.
Provide the expected administration time for each test and the total administration time.
Attach a separate sheet if more space is needed to list tests, versions, or subtests.
Specify total units requested and total time on the form.

Billing Rule

Unit limits noted on form

Certain CPT lines on the form allow only one unit. Ensure you indicate Unit(s) requested and total time requested on the form for each line and for the entire evaluation.

Affected CPT codes: 96130, 96136, 96138
Only one unit allowed for each of the affected codes above
Ensure total units and total time requested are documented on the form

Requested CPT codes

Requested CPT codes (neuropsych testing/evaluation)CPT

96130	Psychological testing evaluation services by physician or other qualified health care professional, first hour
96131	Psychological testing evaluation services, each additional hour
96136	Psychological or neuropsychological test administration and scoring by qualified health care professional, first 30 minutes
96137	Psychological or neuropsychological test administration and scoring by qualified health care professional, each additional 30 minutes
96138	Psychological or neuropsychological test administration and scoring by technician, first 30 minutes
96139	Psychological or neuropsychological test administration and scoring by technician, each additional 30 minutes

Definitions & background

This authorization form is used to request neuropsychological testing coverage for Anthem Blue Cross and Blue Shield products in Indiana (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging / Medicare Advantage). It defines clinical indications, lists required supporting clinical records and prior testing details, and captures requested CPT codes/units for outpatient behavioral health prior authorization.

Definitions

Neuropsychological testingComprehensive evaluation of cognitive, motor, and behavioral functional abilities related to developmental, degenerative, and acquired brain disorders.

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