Psychological testing can be an essential part of mental wellness that can give clarity and understanding about one’s mental health and how to get the best support. However, many individuals wonder about the cost of testing and, specifically, whether insurance covers it or whether there will be out-of-pocket costs.

One of the first factors to determine if psychological testing is covered by insurance is to determine whether the evaluation is medically necessary. Each insurer may have a different definition of medical necessity. However, it generally has to do with whether the evaluation would significantly contribute to the understanding of a particular mental health issue which would logically lead to the initiation of or change to a particular treatment. Medical necessity criteria do not require the individual to follow a particular treatment path. However, the evaluation needs to document that a condition is severe enough where mental health treatment could be reasonably expected to be initiated or changed. Here are some examples where a psychological evaluation may not meet medical necessity criteria:

1. A symptom or problem is very mild and does not impact a person’s home, school, or work life.
2. A problem is purely educational in nature and does not require a medical intervention to treat.
3. The purpose of the evaluation is purely for non-medical reasons, such as related to a lawsuit or court case, is being used in a custody case, or to secure disability benefits or guardianship.

The extent of coverage and requirements depends mainly on your provider, state regulations and the mental health needs of the individual.

Coverage Details for Psychological Testing

Insurance coverage for psychological testing is highly dependent on the concept of medical necessity. Medical necessity refers to whether the testing is considered essential for diagnosing or treating a medical or mental health condition that would cause harm to one’s health without that diagnosis and subsequent treatment. In most cases, insurance providers will not necessarily cover services considered convenient or preventative.

To determine medical necessity, some insurance companies require prior authorization. In this process, your healthcare provider submits a request explaining why the testing is necessary, and your insurance provider determines if the request meets their criteria. This practice was more common in the recent past, and many insurance companies have ended this practice. If you are interested in psychological test, knowing whether your insurer requires prior authorization or a referral from your primary care provider is very important.

The criteria to determine if testing is necessary or covered generally by insurance depends on your state and specific insurance provider. Different states have regulations about mental health coverage, and we recommend you ask your insurance provider about their particular policies and whether or not testing is included, partially covered, or fully covered.

It is not uncommon for insurance companies to integrate some level of cost sharing into their coverage for psychological testing. This means that you will be responsible for a portion of the costs, such as co-pays, deductibles, or co-insurance. Additionally, it’s better to apply for psychological testing with a provider that’s in-network, or covered with your specific health insurance. In-network providers will offer lower out-of-pocket costs, and in-network coverage is recommended, especially if you plan on engaging in treatment following initial testing.

What Tests Are Covered by Insurance?

The types of psychological tests covered by insurance generally depend on whether the tests are considered medically necessary to diagnose a specific condition and inform subsequent treatment. Standard tests that are often covered include behavioral assessments, neuropsychological evaluations, and diagnostic tests to assess specific conditions such as depression, anxiety, or ADHD. In Michigan, the state mandates that autism evaluations must be a covered benefit but there are exceptions to this rule. If you are interested in an autism evaluation for yourself or your child it is important you determine if your insurer is included or excluded from the mandate. If included, your policy will have an “autism rider” attached. To be covered tests need to be evidence-based and rigorously tested to be effective.

Each portion of the evaluation has a current procedural terminology (CPT) code that establishes it as a healthcare service, and each insurance provider covers specific CPT codes when authorized. For example, psychologists typcially bill insurers for the following procedures:

• 96116: Neurobehavioral status exams evaluating thinking, reasoning, and judgment; per hour
• 96121: Each additional hour of the above test
• 96125: Standardized cognitive performance testing; per hour
• 96130: Psychological testing that informs treatment planning and patient feedback; first hour
• 96131: Each additional hour of the above test
• 96132: Neuropsychological testing that informs treatment planning and patient feedback; first hour
• 96133: Each additional hour of the above test
• 96136: Psychological test administration and scoring by a physician; first 30 minutes
• 96137: Each additional 30 minutes of the above test
• 96138: Psychological test administration and scoring by a technician; first 30 minutes
• 96139: Each additional 30 minutes of the above test
• 96146: Electronic psychological test administration and scoring with automated results.

In this example, depending on your coverage with Aetna and if you meet the criteria for these tests, the psychologist will provide billing units that can be applied toward one or more procedure options. Typically billing units are 30-60 minute long sessions, with the first unit billed under one code (e.g. 96130) and subsequent time billed under an additional code (e.g. 96131). Additionally, test administration, interpretation, and scoring are all included within this time.

As a general rule, CPT codes for psychological and neuropsychological testing fall under the prefix 961xx, and the majority fall under 96130-39. Understanding what codes your insurance covers and the degree of coverage ensures you get proper reimbursement and allows you to check coverage before beginning testing.

However, not all tests are automatically covered. Tests primarily used for educational, experimental, or investigational purposes or non-medical purposes are generally not considered necessary by insurance providers.

Are There Exclusions in Coverage?

While insurance may cover a variety of psychological tests, there are some exclusions where coverage is not typically provided. These exclusions do not mean your insurance will not cover testing under these circumstances. It just means that it is unlikely that they will be considered medically necessary and, therefore, will not meet coverage criteria in most cases. To review, common exclusions include:

• Educational Testing: Assessments that are purely educational and not medically necessary, such as for a student’s learning style, school placement evaluations, and giftedness, are not usually covered.
• Legal Testing: Psychological evaluations conducted for court cases, custody arrangements, or other legal purposes are often excluded from coverage as they are not part of medical treatment.
• Experimental or Investigative Testing: Tests that are still in the research phase or are not widely accepted as standard diagnostic tools are not covered by insurance. These tests can inform future CPT criteria and may be covered in the future, but their purpose is to establish standards of testing and not medically necessary.

These exclusions are considered medically convenient, but not medically necessary, meaning that these tests can inform individuals about their mental health and provide essential information. However, for insurance providers, they do not meet the standard of medical necessity and therefore lack of testing will not cause significant harm to the individual.

How to Verify Insurance Coverage for Psychological Testing?

The easiest option to check your insurance coverage is through your provider’s website. Many providers offer online portals where you can log in, review your benefits, and search for covered services, including psychological testing. Alternatively, you can contact your insurance provider directly by phone. Call the number on the back of your insurance card and ask a representative about your coverage for psychological testing, whether prior authorization is needed, and what specific tests are covered.

If you’re unsure where to start, your healthcare provider can help by providing you with the CPT codes for the procedures they plan to use. You can then ask your insurance company to get precise information about what’s covered under your plan. Because there are a lot of CPT codes and overlap in what they represent, we recommend focusing on CPT Codes 96105-96146, which covers psychological and neuropsychological testing services.

Additionally, you can ask your insurance provider about their medical necessity requirements, if you qualify for testing, check if prior authorization is required, and understand out-of-pocket costs, including costs of in-network vs. out-of-network coverage. While the general principles of coverage apply to most insurance companies, your exact coverage and out-of-pocket costs will largely depend on your insurance provider, your healthcare provider’s network coverage, your state, and your unique mental health needs.

Contact Start My Wellness Today to Begin Your Journey with Psychological Testing

Psychological testing is a valuable tool that can provide essential insights into your mental health and guide treatment if you choose to engage in therapy. However, cost is an important consideration, and understanding insurance coverage can make the process smoother, helping you get the most out of testing and avoid unexpected costs.

At Start My Wellness, we understand the complexities of insurance coverage and are here to help you every step of the way. Our experienced team can assist you in determining if psychological testing is in-network with us and covered by your insurance, explaining the process and letting you know of cost estimates before testing begins. We believe mental health services should be as accessible as possible and are committed to helping you navigate the details.

Contact Start My Wellness today at (248)-514-4955 to schedule a psychological testing service and to ask any questions about your insurance coverage and the cost of therapy.

Sources

1. Start My Wellness: Psychological Testing
2. Clinical Ethics: What is Medical Necessity?
3. Start My Wellness: Exploring Psychological vs. Neuropsychological Tests
4. Aetna: Neuropsychological and Psychological Testing
5. American Psychological Association: CPT and Diagnostic Codes
6. American Psychological Association: Psychologists’ testing codes have changed