Psychological and Neuropsychological Testing and Assessment
Customize your policy alerts
Sign up for all harvard pilgrim health care policy alerts
Know when harvard pilgrim health care releases new policies or updates existing guidance.
Monitor payer policy activity
This policy governs coverage and prior authorization requirements for psychological and neuropsychological testing and assessment services for Harvard Pilgrim Health Care (Tufts-related products listed), defining when testing is considered medically necessary and limitations. It affects providers who perform or bill for these assessments for affected members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Limitations
Coverage Criteria and Limitations
Covered when ALL of the following are met:
ALL of the following
- Psychological testing and assessment are performed as part of a medical or behavioral health evaluation to answer a specific clinical question that affects clinical management.
- Neuropsychological testing and assessment are performed when specific cognitive impairments are suspected or identified and when testing addresses questions not answered by prior medical or behavioral health evaluations.
- Prior authorization is obtained when required by the Plan (see coding/prior authorization requirements).
- Services are not performed primarily for educational, vocational, legal, or special education eligibility purposes.
Not covered (any of the following):
- Testing performed primarily to qualify for services covered under state or federal special education laws.
- Testing conducted primarily for educational purposes (including learning disabilities), vocational, or legal purposes.
- Any other contraindication noted within the policy criteria.
CPT / HCPCS Codes
| 96130 | Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour. |
| 96132 | Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour. |
| 96133 | Each additional hour (List separately in addition to code for primary procedure). |
| 96136 | Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional. |
| 96137 | Each additional 30 minutes (List separately in addition to code for primary procedure). |
| 96138 | Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes. |
| 96139 | Each additional 30 minutes (List separately in addition to code for primary procedure). |
| 96146 | Psychological or neuropsychological test administration, with single automated instrument via electronic platform, with automated result only. |
| No codes listed |
Prior Authorization and Provider Responsibilities
Obtain prior authorization using InterQual SmartSheets
Prior authorization is required for psychological and neuropsychological testing and assessment. The Plan requires the use of current InterQual® SmartSheets/Subsets as part of the prior authorization process; providers are recommended to submit prior authorization requests electronically and must choose and complete the appropriate InterQual SmartSheet(s) when obtaining authorization.
- Use the InterQual® SmartSheet(s) identified for Psychological and Neuropsychological Testing and Assessment when submitting a prior authorization request.
- Submit supporting clinical documentation (electronically recommended) with the prior authorization request.
Provider responsibility: authorization is a condition of payment
Ensure any required prior authorization or notification has been obtained as a condition of payment; notification is not required for these services per the form fields, but when notification is required providers may need to supply updated clinical information to qualify for continued service.
- As a condition of payment, confirm that Point32Health (Tufts/Harvard Pilgrim) has received the necessary prior authorization or notification.
- Follow the Plan's directions for submission method (electronic recommended; fax allowed) and provide updated clinical information if requested for continued authorization.
Key Definitions
Outpatient / Testing Services Criteria
Psychological and Neuropsychological Testing Modalities
Psychological and Neuropsychological Testing
Covered when ALL of the following service-specific conditions are met:
ALL of the following
- Psychological testing and assessment are performed by licensed psychologists using norm-referenced psychometric instruments to evaluate behavior, cognition, mood, affect, and/or personality when clinically indicated.
- Neuropsychological testing and assessment are performed to evaluate CNS-related cognitive impairments when clinically indicated and when questions remain after prior evaluation.
Authorization and coding
- Prior authorization is required for specified CPT/HCPCS testing codes per the Plan and must follow the Plan's prior authorization process.
- Providers should use the Plan-specified clinical tools (e.g., InterQual SmartSheets/Subsets) as required to obtain prior authorization for outpatient testing services.
Visit Limits and Related Coding Notes
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.