CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Authorization for Psychological Testing (Coverage Criteria)

This document is an authorization request form and guidance for psychological testing for Anthem Blue Cross and Blue Shield products serving Indiana; it governs required submission elements, supporting documentation, and when testing is appropriate.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyAuthorization for Psychological Testing (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with diagnostic interview, screening results, clinical records, rationale for testing, CPT codes and units using the Availity electronic submission or provided fax methods.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

96130–96139CPT codes listed on form for psychological testing services

One unit onlyCertain CPT codes limited

AvailityPreferred submission

Indiana productsApplies to

Coverage Criteria for Psychological Testing

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Authorization criteria

Authorization for psychological testing is considered when testing is necessary to answer specific clinical questions that cannot be addressed by interview, records review, and screening measures, and when required pre‑testing assessments and documentation are provided.

Preauthorization prerequisites: Diagnostic interview and relevant screening measures completed by the psychologist prior to submission; include clinical/medical records, presenting problems, duration of symptoms, treatment history, and screening results.

Supported by form instructions requiring these elements.

Rationale for testing: Provide a rationale describing the specific clinical questions that cannot be answered by clinical interview, records review, or screening measures, and explain how test results will impact treatment planning.

Rationale section on the form must be completed (describe prior screening measures and why testing is necessary).

Service codes and units: Specify the psychological tests and CPT codes, units requested, and test/subtest names to be administered; indicate any limits on units for certain codes.

Form requires listing of tests and units; certain codes are limited to one unit per request.

Requests for psychological testing for the purposes of placement, disability evaluations, and forensic purposes are not covered benefits and will be denied. Requests for educational testing or educational assessment for learning disabilities should be referred to the public school system and are not covered under this form. Providers must submit psychological testing requests using the appropriate form; neuropsychological and autism testing require their respective forms. Providers contracted through Anthem Blue Cross and Blue Shield product lines serving Indiana should follow their group or network guidelines for authorization and claims submission.

Formal psychological testing is not intended for routine screening or for administration of brief screening measures and inventories. Brief screeners and inventories are expected components of a routine diagnostic evaluation and do not by themselves justify authorization for formal psychological testing.

Provider Submission Requirements and Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for the psychological testing CPT codes listed on the request form. Providers must submit a prior authorization request before rendering services for these codes. Failure to obtain prior authorization will result in denial of payment.

Affected CPT codes: 96130, 96131, 96136, 96137, 96138, 96139
Unit rules: Codes noted as "Only one unit allowed" must follow the single-unit restriction on the request
Submission channels: Fax or electronic prior authorization per payer instructions

Documentation Required

Required Supporting Documentation

Include the following supporting documentation with the prior authorization request to substantiate medical necessity. Incomplete documentation may delay review or result in denial.

Completed request form with member identifiers (name, DOB, member ID)
Date and summary of the diagnostic interview
Pertinent clinical/medical records and psychiatric history
Results and interpretation of screening measures administered prior to testing
Treatment history and rationale explaining why testing is needed beyond clinical interview and records
Previous psychological testing reports (dates/results) if applicable
Specific tests to be administered and time/unit requests tied to each CPT code

Documentation Required

Pre-Testing Assessments Required

A diagnostic interview and relevant screening measures should be completed prior to submission. Document which assessments were administered and include pertinent results with the authorization request.

Diagnostic interview date and brief summary
Screening measures expected prior to submission (examples): Achenbach, ADHD rating scales, BAI, BASC, BDI, other relevant brief inventories
Brief inventories, structured developmental/social history, clinical interview with patient and family interviews as applicable
Pertinent results of screening measures and how they support the need for further psychological testing

Denial Risk

Noncovered Purposes and Educational Testing

Requests for placement, disability determinations, forensic evaluations, or educational testing (refer to public school system) are not covered under this policy and will be denied. Use the testing request form only for clinical psychological testing requests.

Noncovered purposes: placement, disability evaluations, forensic purposes
Educational testing/assessment for learning disabilities should be referred to the public school system

Requested CPT Codes and Billing Guidance

Requested CPT CodesCPT

96130	Psychological testing evaluation services — listed on form (Only one unit allowed)
96131	Psychological testing evaluation services — listed on form
96136	Psychological or neuropsychological test administration by technician — listed on form (Only one unit allowed)
96137	Psychological or neuropsychological test administration by physician/psychologist — listed on form
96138	Psychological or neuropsychological testing interpretation by physician/psychologist — listed on form (Only one unit allowed)
96139	Psychological or neuropsychological testing interpretation by physician/psychologist — listed on form

Psychological Testing Modalities

Psychological testing

Psychological testing — definition and applicability:

Psychological testing: Formal psychological testing refers to standardized test administration and interpretation used to answer specific diagnostic or treatment‑planning questions that cannot be resolved by diagnostic interview, records review, and routine screening measures. It is not intended for routine screening or brief inventories.

Testing is appropriate only when results will affect treatment; screening measures are expected as part of the diagnostic process.