CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Autism Spectrum Disorder (ASD) Testing Authorization Request

Form and requirements for requesting prior authorization of formal psychological testing for Autism Spectrum Disorder (ASD) for Highmark BCBS members in specified New York Medicaid programs; applies to providers submitting ASD testing requests for MMC, HARP, CHPlus, and Essential Plan members.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyAutism Spectrum Disorder (ASD) Testing Authorization Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed ASD testing authorization form via Availity Essentials or the payer portal (or fax) prior to rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MMC/HARP/CHPlus/EPprograms covered (Medicaid populations)

96130-96139CPT codes listed on form

one unit maxunit limits noted

Availity/portal/faxsubmission routes

Coverage Criteria for ASD Testing

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Medical necessity criteria for ASD testing

Covered when ALL of the following are met:

Pre-test clinical evaluation: A diagnostic interview and relevant screening measures/screeners have been completed and documented prior to requesting testing

Form instructs that the psychologist should complete a diagnostic interview and screening measures before submitting testing requests

Supporting documentation provided: Attach relevant clinical/medical records, developmental/social history, observations, speech-language evaluation if applicable, review of academic records/IEP, and screening results

Checklist on form enumerates these items and asks for attached records

Clinical rationale: Provider documents the specific unanswered diagnostic or clinical questions that testing will address and how results will change treatment

Rationale section on form requests description of unanswered questions and impact on treatment

Not for excluded purposes: Request is not for placement, disability evaluation, forensic purposes, or educational/learning disability testing

Form explicitly states these are not covered benefits and refers educational testing to the public school system

Requests for testing that are intended for placement purposes, disability evaluations, forensic purposes, or educational testing/assessment of learning disabilities are not covered benefits and should not be submitted on this authorization form. Educational testing or learning disability assessments should be referred to the public school system. This form applies only to requests for Autism Spectrum Disorder testing and not to other psychological or neuropsychological testing types.

Formal psychological testing is not clinically indicated for routine screening or for the administration of brief behavior screening measures and inventories. Screening measures and brief inventories are expected components of a routine diagnostic evaluation and, except in exceptional cases, a diagnostic interview and relevant screeners should be completed by the psychologist before submitting a testing authorization request.

Provider Actions and Documentation Requirements

Prior Authorization

Prior authorization required — submit completed ASD testing form before services

Submit the completed ASD testing authorization form via Availity Essentials or the payer portal (or fax) prior to rendering services. The form lists CPT codes (96130, 96131, 96136, 96138, 96139) and requests total units/time; include the completed form and signature as part of the submission.

Submit online through Availity Essentials or the provider portal before services are rendered.
Alternatively, fax the completed form to 844-452-8073 prior to rendering services.
Include units/time requested and provider signature on the form.

Step Therapy

Screening first — diagnostic interview and screeners required before testing

Ensure a diagnostic interview and relevant screening measures have been completed and documented before requesting formal psychological testing; testing is not indicated for routine screening or brief behavior inventories.

Complete and document a diagnostic interview (record the interview date on the form).
Administer relevant screening measures prior to submitting the testing request.

Documentation Required

Required supporting documentation — attach clinical records, interview date, and screening results

Attach supporting clinical documentation with the authorization request, including the date of the diagnostic interview, results of prior screening measures, treatment history, and any relevant records (developmental/social history, observations, speech‑language evaluation, academic records/IEP).

Relevant clinical/medical records and the date of the diagnostic interview.
Results of screening measures (examples listed on form: ASRS, SCQ, SRS, MCHAT, CARS, GARS, GADS).
Developmental/social history, observations, speech‑language evaluation when applicable, review of academic records/IEP, and treatment history.
A written rationale describing unanswered diagnostic/clinical questions and how testing will affect treatment (including whether request is to access ABA services).

Denial Risk

Non-covered purposes — placement, disability, forensic, or educational testing

Do not request ASD testing for placement, disability evaluations, forensic purposes, or educational testing/learning disability assessments; such requests are not covered benefits and may be denied.

Refer requests for educational testing or assessment of learning disabilities to the public school system.
Requests for placement, disability evaluations, or forensic purposes are excluded from coverage.

Definitions

Formal psychological testing — definition and scope

DefinitionComprehensive standardized psychological testing administered by a qualified professional following a diagnostic interview and relevant screening measures; intended to address unresolved diagnostic or clinical questions for ASD and not for routine brief screening inventories.

ScopeIncludes administration of standardized evaluation services and test batteries (as listed on the ASD testing authorization form) to answer specific unanswered diagnostic or treatment-planning questions after review of records and screening results.

Pre-test requirementA diagnostic interview and relevant screening measures/screeners must be completed and documented prior to submitting a request for formal psychological testing.

Not indicated forRoutine screening, administration of brief behavior screening measures/inventories, placement purposes, disability evaluations, forensic purposes, or educational/learning disability testing (refer educational testing to public schools).

OpenPayer

Autism Spectrum Disorder (ASD) Testing Authorization Request

Coverage Criteria for ASD Testing

CPT Codes on Authorization Form

Provider Actions and Documentation Requirements

Background

Definitions

Visit Limits and Unit Restrictions

96130	Psychological testing evaluation services (listed on form; one unit maximum noted)
96131	Psychological testing evaluation services (listed on form)
96136	Psychological or neuropsychological test administration/scoring (listed on form; one unit maximum noted)
96138	Psychological or neuropsychological test administration (listed on form; one unit maximum noted)
96139	Psychological or neuropsychological test administration (listed on form)