Psychological testing authorization form and coverage guidance
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Form and instructions for requesting prior authorization for psychological testing for Highmark BCBS MMC/HARP/CHPlus/Essential Plan members; describes required clinical information, screening prerequisites, and lists billable CPT psychological testing codes. Affects providers requesting authorization for psychological testing services for these product lines.
No material clinical or coverage changes in this revision.
Coverage Criteria
Authorization criteria
Covered when ALL of the following are met
Refer to checkboxes for screening tools and clinical interview date.
Use form fields for clinical info, duration, screening measures, and rationale.
Form contains notes like 'Only one unit allowed' for certain codes.
Fax number 1-844-452-8073 provided.
Requests for testing that are intended for placement purposes, disability evaluations, forensic purposes, or educational assessments for learning disabilities are not covered under this process and should be referred elsewhere. Specifically, educational testing or educational assessments for learning disabilities should be referred to the public school system. Providers submitting requests for these purposes should expect that the request may be denied as not a covered benefit.
Formal psychological testing is not indicated for routine screening or for administration of brief behavioral screening measures and inventories. Brief screeners and inventories are expected components of the routine diagnostic process and, other than in exceptional cases, a diagnostic interview plus relevant screening measures should be completed by the psychologist prior to submitting requests for authorization of formal testing.
Provider Actions and Requirements
Prior Authorization Required
Prior authorization required for listed CPT codes — indicate units, specific tests, and testing rationale on the request.
- A completed psychological testing request form must accompany prior authorization requests.
- Specify which test version or subtests will be administered and the number of units requested per CPT code.
Step Therapy
Step therapy: Not applicable. No step therapy requirements for psychological testing under this policy.
Required Supporting Documentation
Required supporting documentation — attach clinical records, prior assessments, and previous testing results (include dates and scores/ratios where applicable).
- Include date of diagnostic interview and results of relevant screening measures or inventories.
- Attach medical, psychiatric, school/IEP records, and any consultations (physician, school, or other relevant parties).
- If retesting, include prior test dates, results, and rationale for repeat testing.
Submission Instructions
Submission instructions — submit requests electronically via Availity or fax to 1-844-452-8073 prior to rendering services; indicate whether testing is for initial evaluation or continuation, and include requested CPT codes and units.
- Use the preferred electronic submission at https://Availity.com.
- If submitting by fax, include the completed psychological testing request form and all supporting documents.
Non‑Covered Purposes
Non-covered purposes — requests for placement, disability evaluations, and forensic purposes are not covered and may be denied. Educational testing or educational assessment for learning disabilities is not covered under this policy and should be referred to the public school system.
- Requests intended for placement decisions, disability determination, or forensic/legal evaluations will be considered non-covered and may be denied.
- Educational assessment requests (e.g., for school learning disability evaluations) should be directed to the member's public school system; these are not covered benefits.
Educational Testing
Educational testing — refer requests for educational assessment for learning disabilities to the public school system; not covered under this policy.
Coding and Billing
| 96130 | Psychological testing evaluation services (listed on form) |
| 96131 | Psychological testing evaluation services (listed on form) |
| 96136 | Psychological or neuropsychological test administration (listed on form) |
| 96137 | Psychological or neuropsychological test administration (listed on form) |
| 96138 | Psychological or neuropsychological test administration (listed on form) |
| 96139 | Psychological or neuropsychological test administration (listed on form) |
Visit Limits and Unit Constraints
Definitions
Background
As background, formal psychological testing is reserved for situations where the diagnostic interview and screening tools do not sufficiently answer the clinical questions. The form emphasizes that brief screening instruments and inventories are part of standard clinical assessment and should be completed and documented (including the date of the diagnostic interview) before requesting authorization for formal testing.
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