CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Psychological Assessment Services — Coverage Criteria

This policy governs outpatient psychological assessment services (including neuropsychological, standardized cognitive, developmental, and speech/language assessments) for Neighborhood Health Plan of Rhode Island members and explains authorization/responsibility based on diagnosis and provider type.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPsychological Assessment Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for medically necessary psychological assessments; medical diagnoses are authorized by Neighborhood Medical Management and behavioral health diagnoses by Beacon Health Strategies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

RequiredPrior auth

<19Child definition

POS 11,22Places of service

96110Reserved CPT

Coverage Criteria for Psychological Assessment Services

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Covered Psychological Assessment Services

Covered when ALL of the following are met

General coverage: Service is an outpatient psychological assessment (including neuropsychological, standardized cognitive performance testing, developmental testing, and speech/language assessment).

Episodes of care may occur in Office (POS 11) or Outpatient (POS 22).

Authorization: Assessment is medically necessary and has prior authorization.

Psychological assessments for medical diagnosis codes are authorized by Neighborhood's Medical Management; assessments for behavioral health diagnosis codes are authorized by Beacon Health Strategies. All services for mental/behavioral health diagnosis codes rendered by a mental/behavioral health provider are processed and paid by Beacon Health Strategies.

Extended Family Planning (EFP) members are excluded from coverage for psychological assessment services under this benefit. In addition, the policy excludes assessments performed for specific non-clinical purposes: evaluations conducted for legal reasons (for example, determination of custody, guardianship, or competency for trial) are not covered. Pediatric developmental testing and autism screening that fall under the Rhode Island EPSDT schedule are treated as primary care services provided by a primary care practitioner and are not covered under this policy.

Psychological assessments and testing performed for legal purposes (including custody, guardianship, or competency determinations) and for academic reasons (including IQ testing and diagnosing learning disabilities) are considered not covered and therefore are not medically necessary under this benefit.

Provider Responsibilities and Authorization

Prior Authorization

Prior Authorization Required

Medically necessary psychological assessments require prior authorization. Assessments for medical diagnosis codes are authorized by Neighborhood's Medical Management team; assessments for behavioral health diagnosis codes are authorized by Neighborhood's behavioral health partner, Beacon Health Strategies. All services for mental/behavioral health diagnosis codes rendered by a mental/behavioral health practitioner/provider are processed and paid by Beacon Health Strategies.

Prior authorization required for psychological assessment services.
Medical-diagnosis assessments: Neighborhood Medical Management reviews and authorizes.
Behavioral-health-diagnosis assessments: Beacon Health Strategies authorizes and processes claims (beaconhealthstrategies.com).

Documentation Required

Actionable provider note

Providers: ensure authorization is obtained from the correct reviewer based on the member's diagnosis code and provider type. Use CPT code 96110 for pediatric developmental testing and autism screening per Neighborhood's claims system; these primary care services are not processed here.

Verify the member's diagnosis code to determine whether Neighborhood Medical Management or Beacon Health Strategies authorizes the assessment.
Reserve CPT 96110 for pediatric developmental testing and autism screening; see the Children's Care Benefit Coverage Summary for details.
For claim submission, include the appropriate diagnosis code and provider specialty to route to the correct payer/partner.

Denial Risk

Not Covered — Denial Risk

Psychological assessments and testing for legal purposes (custody, guardianship, competency) or for academic reasons (IQ testing, learning disability diagnosis) are not covered and represent a denial risk. Extended Family Planning (EFP) members do not have this benefit in their restricted package.

Not covered: assessments for legal reasons (custody, guardianship, competency).
Not covered: assessments for academic reasons (IQ testing, learning disability diagnosis).
Not covered for EFP members—benefit excluded from their package.

Background

Psychological Assessment Services encompass a range of outpatient testing modalities, including neuropsychological testing, standardized cognitive performance testing, developmental testing, and speech and language assessment. Authorization and payment responsibility vary by diagnosis and provider type: medical diagnoses are authorized by Neighborhood Medical Management while behavioral health diagnoses are authorized by Beacon Health Strategies. Episodes of care typically occur in Office (POS 11) or Outpatient (POS 22) settings.

Definitions

inv-11: Child — For claims, a child is a member under 19 years (0-18.99 years)

DefinitionFor claims, a child is a member under 19 years (0–18.99 years)

System contextThis definition is specific to the Neighborhood claims system and aligns pediatric processing rules

RelevanceDetermines application of pediatric coding and benefit packages for psychological assessment services

inv-12: Psychological Assessment Services — definition covering outpatient neuropsychological, standardized cognitive, developmental, speech/language testing

ScopeOutpatient services involving psychological testing such as neuropsychological, standardized cognitive performance, developmental, and speech/language assessments

Examples of testsNeuropsychological testing, standardized cognitive performance testing, developmental testing, speech and language assessment

Authorization impactMedical review and claims processing depend on diagnosis code(s) and provider type; authorization routing differs for medical vs behavioral diagnoses