Autism Spectrum Disorder (ASD) Testing Authorization Request
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This document is an authorization request form governing prior authorization for formal psychological testing for Autism Spectrum Disorder for Empire Bluecross members in New York; it specifies required clinical information and documentation providers must submit before testing is performed.
No material clinical or coverage changes in this revision.
Coverage Criteria for ASD Psychological Testing
Initial testing coverage criteria
Covered when ALL of the following are met
Form includes checklist of required assessments (see screening measures).
Screener names listed on form.
Form contains detailed treatment history sections.
Rationale section on form.
Explicit exclusions listed on form.
Requests for psychological testing submitted for placement purposes, disability evaluations, or forensic purposes are not covered benefits and will be denied. Educational testing or assessment of learning disabilities should be referred to the public school system. This authorization form applies only to Autism Spectrum Disorder (ASD) testing; requests for other psychological or neuropsychological testing must be submitted on the appropriate forms.
Formal psychological testing is not clinically indicated for routine screening or for administration of brief behavior screening measures and inventories. Brief screening tools and inventories are expected elements of a routine diagnostic evaluation and, except in exceptional cases, should be completed as part of the clinical interview and assessment before requesting authorization for formal testing.
Coding — CPT / Billing Codes
| 96130 | Psychological testing evaluation services (one unit maximum) - listed on form |
| 96131 | Psychological testing evaluation services - listed on form |
| 96136 | Psychological testing administration (one unit maximum) - listed on form |
| 96137 | Psychological testing administration - listed on form |
| 96138 | Psychological testing evaluation services (one unit maximum) - listed on form |
| 96139 | Psychological testing evaluation services - listed on form |
Provider Actions, Authorization & Documentation Requirements
Prior Authorization Required
Prior authorization is required before services are rendered. Submit prior authorization requests online through Availity Essentials (https://Availity.com) or via the provider link at https://anthembluecross.com/ny/provider. This form must be completed and submitted prior to rendering services.
- Submit online via Availity Essentials or the Anthem provider link
- Fax submission allowed to 844-430-1703
Provider action / Alert
Complete all provider information fields on the request form, including the administering professional if different from the billing provider. Indicate whether services will be rendered in-person or via telehealth and provide servicing address.
- Include provider name, phone, fax, NPI, tax ID, address, email
- Include billing facility/group name, NPI, tax ID, and address
- Specify whether services are in-person or via telehealth
Required Supporting Documentation
Attach supporting documentation to the authorization request. This should include the date of the diagnostic interview, relevant clinical and medical records, screening measures used, treatment history, and a clear clinical rationale describing what diagnostic questions remain and how testing results will impact treatment.
- Date of diagnostic interview
- Relevant clinical and medical records
- Brief inventories and/or screening measures and results
- Treatment history and prior interventions
- Clear rationale answering diagnostic questions remaining and impact on treatment
Noncovered Purposes — Denial Risk
Requests for placement, disability evaluations, forensic purposes, and educational testing are not covered and will be denied. Refer requests for educational testing or learning disability assessments to the public school system. Psychological testing forms for non-autism testing (e.g., general psychological or neuropsychological testing) must be submitted on their respective forms.
- Not covered: placement, disability evaluations, forensic purposes
- Refer educational testing/learning disability assessment to public schools
- Use the appropriate form for psychological or neuropsychological testing if request is not for autism testing
Behavioral and Therapy History Requirements
Behavioral and therapy history
Multiple therapy lines present in treatment history sections.
Definitions
Background and Rationale
Background: Formal psychological testing differs from brief behavior screening measures and inventories. The policy clarifies that formal testing is not indicated for routine screening; instead, clinicians should perform a diagnostic interview and complete relevant brief screening instruments prior to submitting a testing authorization request. This form is limited to ASD testing requests and directs providers to use other required forms for psychological or neuropsychological testing outside of ASD.
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