Psychological/Neuropsychological Testing Prior Authorization Request
Customize your policy alerts
Sign up for all Bluecross Idaho policy alerts
Know when Bluecross Idaho releases new policies or updates existing guidance.
Monitor payer policy activity
This document governs prior authorization submission requirements and processing for psychological and neuropsychological testing requests for Bluecross Idaho members and instructs providers what documentation is required for review.
No material clinical or coverage changes in this revision.
Coverage Criteria for Psychological and Neuropsychological Testing
Authorization coverage criteria
Covered when ALL of the following are met:
Required documentation; request will not be processed without it.
Required documentation; request will not be processed without it.
Missing data may delay processing.
Submission timing requirement; elective requests submitted <10 days may be delayed.
Authorization length limitation.
Requests that do not include a diagnostic assessment completed within the last 30 days by a behavioral health professional, or that lack at least one validated symptom inventory or rating scale, will not be processed. In addition, incomplete form data (for example, missing patient demographics, ICD‑10 diagnosis, requested CPT codes and units, total time requested, list of tests, clinical formulation/summary, or the psychologist’s signature) may result in processing delays or denial.
Providers must ensure the submitted authorization form is fully complete and includes the required recent assessment and rating scales before submission. The form itself states that missing data may result in processing delay, and the policy requires these items as mandatory supporting documentation.
Testing will be considered not indicated when the clinical question can be answered by a diagnostic interview, review of existing medical or behavioral records, or a second opinion. The form explicitly asks providers to state “What is the question to be answered by testing that cannot be determined by a diagnostic interview, review of medical/behavioral records or second opinion?” and requires justification when testing is requested for questions that could be resolved without formal testing.
When the rationale for testing does not clearly explain why interview or record review is insufficient, the request may be denied or returned for clarification; providers should document how test results will change diagnosis or treatment to support medical necessity.
Coding and Authorization Period
| 96105 | Assessment of Aphasia and Cognitive Performance Testing, per hour |
| 96125 | Standardized cognitive performance testing, per hour |
| 96110 | Developmental/Behavioral screening and testing, per standardized instrument |
| 96112 | Developmental testing by qualified health care professional, first hour |
| 96113 | Each additional 30 minutes of developmental testing |
| 96127 | Brief emotional/behavioral assessment with scoring and documentation |
| 96116 | Neurobehavioral status exam by qualified health care professional, first hour |
| 96121 | Neurobehavioral status exam each additional hour |
| 96130 | Test evaluation services, first hour |
| 96131 | Test evaluation services, each additional hour |
Provider Submission and Documentation Requirements
Prior authorization required; timing rules
Prior authorization is required for psychological and neuropsychological testing. Submit elective prior authorization requests at least 10 days prior to the scheduled date of service; urgent requests should be indicated on the form and routed via the urgent behavioral health fax number provided.
- Elective requests: submit >= 10 days before date of service.
- If urgent, check the urgent box on the form and use Behavioral Health fax 208-387-6840.
Complete the form and attachments to avoid delays
Ensure the testing request form is fully completed and all required attachments are included before submission; incomplete forms or missing documentation can delay processing or result in denial.
- All information requested on this form must be complete; missing data may result in processing delay.
- Include clinical formulation/summary and psychologist signature on the form.
Include recent diagnostic assessment and validated inventories
Attach a diagnostic assessment completed within the last 30 days by a behavioral health professional and at least one validated symptom inventory or rating scale; the request will not be processed without these documents.
- Diagnostic assessment must be completed within 30 days of the request.
- At least one validated symptom inventory or rating scale must be included.
Complete required form data elements
Complete all required form data elements: patient demographics; requesting and testing provider names, IDs, and contact information; ICD-10 diagnosis with description; requested CPT codes and units; total time requested; list of tests; referring provider; clinical formulation/summary; current medications; and signature of the psychologist.
- Patient name, enrollee ID, DOB, and contact details.
- Requesting provider and testing provider name/credentials, provider IDs, addresses, phone, fax, and email.
- ICD-10 diagnostic code(s) with description(s).
- Requested CPT codes and number of units, and total time requested.
- List of tests to be administered and clinical formulation/summary.
- Signature of psychologist with credentials and date.
Missing documentation will halt processing
Requests missing the required diagnostic assessment (within 30 days) and at least one validated symptom inventory or rating scale, or with incomplete form data, will not be processed and may be denied or delayed.
- Requests lacking the recent diagnostic assessment or validated rating scales will not be processed.
- Incomplete form information may result in processing delay or denial.
Background
Psychological and neuropsychological testing are tools used to evaluate cognitive, behavioral, developmental, and emotional functioning to inform diagnosis and treatment planning. The Bluecross Idaho form requires a clinical formulation/summary, patient history, current mental health services, substance use and neurological history, and a clear statement of how testing results will be used to determine or modify treatment.
The policy emphasizes that testing requests must include recent clinical context and rationale: a diagnostic assessment within the last 30 days, at least one validated symptom inventory or rating scale, and a description of the specific question testing is intended to answer that cannot be resolved by interview or record review. Test selection and requested CPT codes, total time, and a list of tests to be administered must also be provided so reviewers can determine appropriateness and scope of the evaluation.
Test Types and Definitions
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.