CurrentlucetPolicy N/A

Request for Psychological Testing — form and submission instructions

Governs completion and submission of psychological testing authorization requests to Lucet for behavioral health testing services; affects providers submitting testing requests and Lucet internal review teams.

Policy Summary

Payerlucet

PolicyRequest for Psychological Testing — form and submission instructions

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateN/A

Next Review DateN/A

Key ActionComplete the form including DSM-5/ICD-10 diagnosis codes and list total testing hours/units next to each requested CPT code.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

96116–96146CPT range referenced

816-416-7788Lucet employee fax

3Form content pages

Coverage Criteria and Required Submission Information

Form submission and required fields

Authorization determination depends on the insurer and the documentation supplied. Complete all required fields and attach supporting documentation; include diagnosis codes, testing rationale, prior testing history, and units requested.

Complete all required form fields (type or print legibly) including patient and provider identification, dates of testing, referral source, and contact information.

Provide a DSM-5 or ICD-10 behavioral health diagnosis code (use an F code). Note: the diagnosis code submitted with the claim will determine which benefit rule applies.

Indicate whether the request is retrospective. If Yes, attach documentation of testing for retrospective authorization review.

List dates of prior testing and names of prior testing tools; describe history of psychiatric treatment and current psychotropic medications.

Policy Summary

Payerlucet

PolicyRequest for Psychological Testing — form and submission instructions

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateN/A

Next Review DateN/A

Key ActionComplete the form including DSM-5/ICD-10 diagnosis codes and list total testing hours/units next to each requested CPT code.

SourceLink

On This Page

CPT Codes and Unit Mapping for Psychological Testing

Psychological testing CPT codes referenced on formCPTCovered

96116	Neuropsychological/psychological testing service (unit basis as described on form)
96121	Add-on code referenced in mapping to 96116 units
96130	Testing code referenced in mapping
96131	Add-on code referenced in mapping to 96116 units
96132	Testing code referenced in mapping
96133	Add-on code referenced in mapping
96136	Testing code referenced in mapping
96137	Add-on code referenced in mapping
96138	Testing code referenced in mapping
96139	Add-on code referenced in mapping

1–10 of 11

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Mapping of 96116 units to CPT codes

96116 unit 1 mapping96116,1 = 96121 (add-on code)

96116 unit 2 mapping96116,2 = 96130

96116 unit 3 mapping96116,3 = 96131 (add-on code)

96116 unit 4 mapping96116,4 = 96132

96116 unit 5 mapping96116,5 = 96133 (add-on code)

96116 unit 6 mapping96116,6 = 96136

96116 unit 7 mapping96116,7 = 96137 (add-on code)

96116 unit 8 mapping96116,8 = 96138

96116 unit 9 mapping96116,9 = 96139 (add-on code)

96116 unit 10 mapping96116,10 = 96146

96116 unit 11 mapping96116,11 = Other

Provider Submission Requirements and Actions

Prior Authorization

Request submission and CPT unit reporting

Type or print neatly in the designated fields. Complete all fields. Write the numerical diagnosis code(s) from the DSM-5 or ICD-10. Enter the total number of testing hours or units requested next to the appropriate CPT code(s) listed on the form.

Include DSM-5/ICD-10 diagnosis code(s) (use F-codes for behavioral health when applicable).
List the total testing hours/units next to each requested CPT code on the form.
Indicate the number of units requested per code (note: for some codes 1 unit = 1 hour; for others 1 unit = 30 minutes).
If retrospective request, attach documentation of testing for retrospective authorization review.

Documentation Required

Submission and verification

Return requests and supporting documentation via fax to the appropriate number for verification or routing. If the member is covered as an employee of Lucet or a spouse/dependent of a Lucet employee, return by fax to the Internal Behavioral Health Benefit Review team at 816-416-7788 or 816-237-2364. For verification of benefits, eligibility, authorization requirements, and allowable codes, call the customer service number on the member's insurance ID card.

Fax completed form and any attachments to the appropriate fax number listed for the payer or Lucet internal team.
Verify benefits, eligibility, and authorization requirements by calling the member’s plan customer service number on the insurance ID card before submission when needed.
Lucet employees or dependents: use internal Behavioral Health Benefit Review team fax routing noted above.

Definitions and Special Submission Scenarios

DSM-5 or ICD-10 diagnosis code (numeric requirement)

Required diagnosis code formatWrite the numerical diagnosis code(s) from the DSM-5 or ICD-10 (Current ICD-10 Behavioral Health Diagnosis Code should be an F code)

Diagnosis code determines benefit ruleThe diagnosis code submitted with the claim will determine which benefit rule applies when the claim is submitted

Medical vs behavioral diagnosesMedical diagnoses should be authorized and billed through the Health Plan; behavioral health F codes are used for testing authorization

Request submitted after testing has occurred

Retrospective request indicatorIs this a Retrospective Request? If Yes, attach documentation of testing for retrospective authorization review

Attach testing documentationWhen submitting a retrospective request, include documentation of the testing performed (dates, tools, results as applicable)

Form field to indicate retrospective statusThe form includes a checkbox: Is this a Retrospective Request? (Yes/No)