Psychological Testing Authorization for New York Medicare Advantage
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Governs authorization requests for formal psychological testing for New York Medicare Advantage members, clarifies required supporting information and permitted CPT codes, and notes certain purposes (placement, disability, forensic, educational) are not covered.
No material clinical or coverage changes in this revision.
Coverage Criteria for Psychological Testing
Authorization criteria
Covered when adequate clinical justification and prior steps are documented.
Core requirements
- Date of diagnostic interview (provide date).
Per form instructions
- Which screening measures and brief inventories were completed and pertinent results (list measures and results).
Indicate screening measures administered prior to the testing request (e.g., clinical interview, Achenbach, ADHD rating, BDI, CBCL, etc.).
- Presenting problems and duration of symptoms (specify problems and duration).
- Relevant treatment history (frequency, duration, current treatment status).
- Rationale describing what current questions cannot be answered by clinical interview, review of records, or screening measures, and how testing results will impact treatment (describe specific clinical questions and expected management changes).
See 'Rationale for testing' section
- Supporting clinical/medical records attached (relevant medical records, academic records/IEP if applicable, consultations).
Requests for psychological testing submitted for the purposes of placement, disability evaluations, or forensic purposes are not covered benefits and should not be submitted on this form. Educational testing or assessments for learning disabilities should be referred to the public school system rather than requested through this authorization process.
Permitted CPT Codes for Psychological Testing
| 96130 | Psychological testing evaluation services (listed on form) |
| 96131 | Psychological testing evaluation services (listed on form) |
| 96136 | Psychological testing administration and scoring (listed on form) |
| 96137 | Psychological testing administration and scoring (listed on form) |
| 96138 | Psychological testing interpretation (listed on form) |
| 96139 | Psychological testing interpretation (listed on form) |
Provider Authorization and Documentation Requirements
Prior authorization required for CPT 96130–96139
Prior authorization is required for psychological testing requests that bill CPT codes 96130–96139. Submit the specified Request for Authorization: Psychological Testing form electronically (preferred) via Availity or by fax as indicated on the form.
Complete diagnostic interview and screening measures before authorization
Except in exceptional cases, the psychologist must complete a diagnostic interview and relevant screening measures before submitting an authorization request for psychological testing.
- Formal psychological testing is not indicated for routine screening; brief inventories/screeners are expected parts of the diagnostic process
- Date of diagnostic interview should be provided on the form
Submit completed request form with supporting records and rationale
Include the completed psychological testing request form plus supporting clinical/medical records and documentation showing the diagnostic interview date, which screening measures were administered, treatment history, and the rationale for testing.
- Attach relevant medical records and clinical diagnostic assessments
- Provide rationale explaining what current questions cannot be addressed by interview/records/screeners and how results will impact treatment
- Specify tests and CPT codes requested and the number of units (form includes fields for test names and units)
Do not request testing for placement, disability, forensic, or educational purposes
Requests submitted for placement purposes, disability evaluations, and forensic purposes are not covered; requests for educational testing/assessment for learning disabilities should be referred to the public school system.
- Do not submit authorization requests for placement, disability, or forensic evaluations—these are not covered benefits
- Refer educational testing/assessment for learning disabilities to the public school system
Background and Rationale
Formal psychological testing (the structured, billable services captured by CPT codes listed on the testing request form) is not indicated for routine screening or for brief behavioral health inventories. Routine diagnostic workups are expected to include a diagnostic interview and appropriate screening measures; formal testing should be reserved for situations where those steps and a clear clinical rationale demonstrate that interview, record review, and brief screeners cannot answer the clinical question and that test results will meaningfully affect treatment planning.
Key Definitions
Service Unit Limits
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