CurrentFidelis CarePolicy N/A

Psychological and Neuropsychological Testing Request

Form and authorization guidance for requesting psychological and neuropsychological testing for Fidelis Care members, including required supporting documentation and CPT codes for billed services. Affects ordering providers, testing providers, and utilization reviewers.

Policy Summary

PayerFidelis Care

PolicyPsychological and Neuropsychological Testing Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed testing request form and supporting documentation (including court order if testing is court-ordered) to 833-561-0094 for authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12distinct CPT codes listed

Fax: 833-561-0094submission

Authorization not guaranteepayment notice

Coverage Criteria — Psychological & Neuropsychological Testing

General authorization criteria

Authorization is approved when the completed testing request form and required supporting documentation are provided and the clinical rationale for testing is documented.

Policy Summary

PayerFidelis Care

PolicyPsychological and Neuropsychological Testing Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed testing request form and supporting documentation (including court order if testing is court-ordered) to 833-561-0094 for authorization.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Primary requirements: Completed testing request form faxed to 833-561-0094; attach all related medical consult/referral reports; document current symptoms and functional impairments and the referral source; indicate whether prior psychological/neuropsychological testing, diagnostic testing (e.g., CT/CAT scan, EEG, MRI), school-based psychological evaluations, or psychiatric/psychological consultations have been performed; document current or recent substance use history and current psychotropic medications (include dose and start date); identify whether testing is court-ordered (if yes, include court order) and whether testing is for pre-surgical or benefits/vocational eligibility purposes; list the names of tests requested.

Provider must complete and fax the form with supporting documentation as listed on the form.

CPT Codes and Billing Categories

Developmental TestingCPTCovered

96112	Developmental Testing (first hour)
96113	Developmental Testing (each additional 30 minutes)

Developmental Testing (duplicate) - source indexmixed

No codes listed

Neurobehavioral Status ExamCPTCovered

96116	Neurobehavioral Status Exam (first hour)
96121	Neurobehavioral Status Exam (each additional hour)

Test Administration (Psychological/Neuropsychological)CPTCovered

96136	Test Administration by Professional (first 30 minutes)
96137	Test Administration by Professional (each additional 30 minutes)
96138	Test Administration by Technician (first 30 minutes)
96139	Test Administration by Technician (each additional 30 minutes)

Psychological Test Interpretation/ReportCPTCovered

96130	Test Interpretation/Report Writing/Feedback - Psychological (first hour)
96131	Test Interpretation/Report Writing/Feedback - Psychological (each additional hour)

Neuropsychological Test Interpretation/ReportCPTCovered

96132	Test Interpretation/Report Writing/Feedback - Neuropsychological (first hour)
96133	Test Interpretation/Report Writing/Feedback - Neuropsychological (each additional hour)

Computerized TestingCPTCovered

96146

Computerized Testing (per instrument)

Provider Submission, Authorization, and Billing Notices

Documentation Required

Submission and required supporting documentation

Providers must submit the completed Psychological/Neuropsychological Testing Request form and all required supporting documentation for authorization. Fax the completed form and attachments to 833-561-0094. Supporting documentation includes medical consult/referral reports, prior testing or diagnostic study reports (e.g., CAT scan, EEG, MRI), school-based psychological evaluations, psychiatric/psychological consultation notes, medication history, and a court order when testing is court-ordered.

Fax completed request form and supporting documentation to 833-561-0094.
Attach all related medical consult/referral reports and prior testing/diagnostic study results (e.g., CAT, EEG, MRI).
Include school-based psychological evaluations and psychiatric/psychological consultation notes when available.
If testing is court-ordered, include the court order with the request form.
List names of tests requested and relevant ICD-10 diagnosis prompting testing.

Prior Authorization

Prior Authorization Required

Authorization of the requested psychological/neuropsychological testing is required prior to performing the services. Authorization does not guarantee reimbursement.

Obtain prior authorization before scheduling or performing testing.
Authorization is not a determination of payment — reimbursement is subject to the provider's contract with Fidelis Care.

Denial Risk

Authorization and billing notice — Reimbursement risk

Authorization does not ensure reimbursement. Providers are responsible for consulting their individual provider-specific contracts to determine payment terms and are liable for any non-covered or non-reimbursed services.

Authorization is not a guarantee of payment — payment depends on provider-specific contract terms.
Providers should verify coverage and reimbursement rules with Fidelis Care and their contract prior to providing services.

Background and Purpose

The request form collects detailed clinical and administrative information to support authorization decisions. Required fields capture the referral source and instructions to attach related medical consult/referral reports; the current symptoms and functional impairments motivating testing; whether testing addresses unanswered diagnostic questions and how results will be used; history of prior psychological/neuropsychological testing; any prior diagnostic imaging (e.g., CT/CAT, EEG, MRI); school-based psychological evaluations; psychiatric or psychological consultations; current or recent substance use; and current psychotropic medications (including dose and start date). The form also asks whether testing is court-ordered (and requires the court order if yes), whether testing is for pre-surgical purposes, and whether it is for benefits/vocational eligibility, plus the names of tests requested.

Definitions and Test Type Summary

Neurobehavioral Status Exam (96116/96121)

DefinitionNeurobehavioral Status Exam — standardized clinical assessment of cognitive/behavioral functioning (CPT 96116 for the first hour; CPT 96121 for each additional hour).

Typical useBrief to extended evaluation of attention, memory, language, executive function, mood/behavior to document current neurobehavioral status.

Billing unitsReport CPT 96116 for the first hour of professional time; report CPT 96121 for each additional hour of professional time.

ProviderPerformed and billed by qualified behavioral health professionals as specified by CPT guidance (professional administration).

Test types and billing

Developmental testing codesCPT 96112 (first hour) and CPT 96113 (each additional 30 minutes).

Test administration codesCPT 96136/96137 for administration by a professional (first 30 minutes, each additional 30 minutes) and CPT 96138/96139 for administration by a technician (first 30 minutes, each additional 30 minutes).

Interpretation/reporting codesPsychological interpretation/reporting: CPT 96130 (first hour) and CPT 96131 (each additional hour); Neuropsychological interpretation/reporting: CPT 96132 (first hour) and CPT 96133 (each additional hour).

Computerized testing codeCPT 96146 billed per instrument for computerized psychological/neuropsychological testing.

Submission noteInclude completed testing request form and supporting documentation (e.g., consult/referral reports, court order if testing is court‑ordered) when requesting authorization; fax to 833-561-0094.