CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Psychological and Neuropsychological Testing Services Coverage Criteria

Defines Neighborhood Health Plan of Rhode Island coverage, coding, and documentation requirements for psychological and neuropsychological testing services for Medicaid (excluding EFP), INTEGRITY, and Commercial members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPsychological and Neuropsychological Testing Services Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionVerify member eligibility, coverage, and prior authorization criteria before rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicaid, INTEGRITY, CommercialPlan types covered

96116-96139, 96146CPT codes listed

2025-09-01Effective

Coverage Criteria

General medical necessity and documentation

Covered when services are medically necessary and supported by documentation.

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General requirement: All services must be medically necessary to qualify for reimbursement.

Neighborhood may use NCDs, LCDs, InterQual, EOHHS recommendations, and Clinical Medical Policies to determine medical necessity.

Provider responsibility: The provider must verify member eligibility, benefit coverage, and any prior authorization requirements prior to rendering services.

Refer to Neighborhood's plan specific Prior Authorization Reference page and Clinical Medical Policies; contact Provider Services at 1-800-963-1001 for questions.

Documentation in the medical record must support the service(s) billed and the medical necessity of the service(s).

Neighborhood reserves the right to request medical records for any service billed and follows CMS standards for documentation.

This policy is informational and is not a guarantee of reimbursement. Claim payments and reimbursement for psychological and neuropsychological testing services are subject to member eligibility, benefit coverage, claims payment edit rules, coding and documentation guidelines, authorization policies, provider contract agreements, and applicable state and federal regulations. Neighborhood may audit billed services and the policy may be updated; providers should verify plan-specific requirements before rendering services.

Coding

Neurobehavioral status examCPT

96116	Neurobehavioral status exam; first hour
96121	Neurobehavioral status exam; each additional hour

Psychological / Neuropsychological testing and administrationCPT

96130	Psychological testing evaluation services; first hour
96131	Psychological testing evaluation services; each additional hour
96132	Neuropsychological testing evaluation services; first hour
96133	Neuropsychological testing evaluation services; each additional hour
96136	Psychological or neuropsychological test administration and scoring by qualified professional; first 30 minutes
96137	Psychological or neuropsychological test administration and scoring by qualified professional; each additional 30 minutes
96138	Psychological or neuropsychological test administration and scoring by technician; first 30 minutes
96139	Psychological or neuropsychological test administration and scoring by technician; each additional 30 minutes
96146	Psychological or neuropsychological test administration with single automated, standardized instrument via electronic platform, with automated result only

Provider Actions and Requirements

Prior Authorization

Verify prior authorization and eligibility

Verify member eligibility, coverage, and any required prior authorization before providing services; providers are directed to Neighborhood's plan-specific Prior Authorization Reference page for details and may contact Provider Services for questions.

It is the provider's responsibility to verify eligibility, coverage and authorization criteria prior to rendering services.
Refer to Neighborhood's plan specific Prior Authorization Reference page for plan-specific rules.

Note

Medical necessity frameworks used for authorization

Neighborhood may determine medical necessity using national and local coverage determinations, industry-accepted criteria (e.g., InterQual), EOHHS recommendations, and its Clinical Medical Policies; providers should expect these frameworks to be applied during authorization reviews.

National Coverage Determination (NCD) and Local Coverage Determination (LCD)
Industry accepted criteria such as InterQual
Rhode Island EOHHS recommendations and Neighborhood Clinical Medical Policies

Documentation Required

Support billed services with medical record documentation

Medical record documentation must support the services billed and demonstrate the medical necessity of those services; Neighborhood follows CMS documentation standards.

Documentation in the medical record must support the service(s) billed as well as the medical necessity of the service(s).
Neighborhood follows CMS standards for proper documentation requirements.

Denial Risk

Denials for insufficient documentation

Neighborhood may request medical records for any billed service and may deny claims if documentation does not support the billed services or medical necessity.

Neighborhood reserves the right to request medical records for any service billed.
Lack of documentation supporting billed services and medical necessity may trigger denial.

Background

This policy governs coverage and reimbursement for psychological and neuropsychological testing services, which assess cognitive, behavioral, and psychological functioning to inform diagnosis, treatment planning, and recommendations for disability or educational services. It defines the requirements for medical necessity, coding, documentation, and prior authorization that apply to Neighborhood Health Plan of Rhode Island Medicaid (excluding EFP), INTEGRITY, and Commercial members. Services are covered only when medically necessary and supported by documentation in the medical record.

Definitions

Neurobehavioral status exam (96116, 96121)

CPT codes96116 (first hour); 96121 (each additional hour)

Scope of assessmentClinical assessment of thinking, reasoning, and judgment (e.g., acquired knowledge, attention, language, memory, planning and problem solving, visual spatial abilities)

Service componentsIncludes both face-to-face time with the patient and time interpreting test results and preparing the report

Billing note96121 is listed separately in addition to the primary procedure when used for additional hours

Psychological testing evaluation (96130, 96131)

CPT codes96130 (first hour); 96131 (each additional hour)

Core servicesIntegration of patient data; interpretation of standardized test results and clinical data; clinical decision making; treatment planning; report; interactive feedback to patient, family, or caregiver when performed

Billing note96131 is listed separately in addition to the primary procedure when used for additional hours

ProviderPerformed by a physician or other qualified health care professional

Neuropsychological testing evaluation (96132, 96133)

CPT codes96132 (first hour); 96133 (each additional hour)

Relationship to psychological testingParallels psychological testing evaluations in content (integration, interpretation, decision making, treatment planning, report, feedback) but specific to neuropsychological assessment

Billing note96133 is listed separately in addition to the primary procedure when used for additional hours

ProviderPerformed by a physician or other qualified health care professional