Autism Spectrum Disorder (ASD) Testing Authorization Request
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria for ASD Testing
Medical necessity criteria for ASD testing
Covered when ALL of the following are met:
Form instructs that the psychologist should complete a diagnostic interview and screening measures before submitting testing requests
Checklist on form enumerates these items and asks for attached records
Rationale section on form requests description of unanswered questions and impact on treatment
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.
CPT Codes on Authorization Form
| 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) |
Provider Actions and Documentation Requirements
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.
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.
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).
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.
Background
The intent of formal psychological testing for ASD is to resolve specific, unanswered diagnostic or clinical questions after a diagnostic interview, review of records, and appropriate screening measures have been completed. Test results should provide information that affects diagnosis or treatment planning; therefore testing should follow—not replace—the diagnostic interview and initial screening steps.
Definitions
Visit Limits and Unit Restrictions
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