Prior Authorization Request (Neuropsychological Testing)

Date of Request: [Date of request]

Request Type: [standard / expedited] (If expedited, include brief reason)

Requested Service Date Range: [Start date – End date]

Patient Name: [Full name]

Date of Birth: [MM/DD/YYYY]

Member ID: [Insurance member ID]

Insurance Plan: [Plan name]

Ordering Provider: [Name, credentials, NPI, practice name, phone, fax]

Rendering Provider: [Name, credentials, specialty, NPI] (If same as ordering provider, state "Same as ordering provider")

Place of Service: [POS code and description]

Request Summary

Requested Service: [Comprehensive neuropsychological evaluation/testing]

Primary Referral Question: [One-sentence statement of the key clinical question]

Suspected Diagnosis Category and Rationale for Timing: [Diagnostic category and why testing is indicated now]

Medical Necessity Statement: [One sentence linking symptoms to functional impairment and how results will change clinical management]

Total Time Requested and Staffing: [Total hours] ([Neuropsychologist hours] neuropsychologist; [Technician hours] technician)

Referral Question and Decision Targets

• Referral Source and Reason: [Referring provider/service and stated reason for referral]
• Diagnostic Clarification: [Specific differential diagnoses to adjudicate]
• Severity/Domain Characterization: [Domains to quantify and characterize]
• Functional Implications: [Work/school, ADLs/IADLs, safety/driving, independent living, capacity considerations]
• Treatment Planning Needs: [Rehabilitation, medication management, psychotherapy focus, accommodations, caregiver supports]
• Why Brief Screening/Interview Alone Is Insufficient: [Patient-specific limitations of screening tools; need for standardized, norm-referenced testing and validity assessment]

Medical Necessity Narrative

Presenting Symptoms and Functional Impairment: [Cognitive, behavioral, and/or emotional symptoms with onset, duration, course, and triggers; attribute sources: patient report, collateral informant, chart review, referring provider]

• Objective Functional Impact: [Specific examples: work/school performance decline; ADLs/IADLs such as medication management, finances, driving; safety incidents; social/communication changes]
• Trajectory and Red Flags: [Worsening/stability/fluctuation; concerning features]

Pertinent History Supporting Medical Necessity and Test Selection:

• Neurologic History: [TBI, stroke, seizures, tumor, infection, demyelinating disease, movement disorder with dates and severity] (If none, state "No known neurologic disease or event.")
• Psychiatric History and Current Stability: [Diagnoses, treatments, current symptom control] (If none, state "No significant psychiatric history reported.")
• Developmental History: [Learning/developmental disorders, special education, IEP/504] (Include only if relevant; if payer expects explicit negatives, state "No known developmental delays.")
• Medical Comorbidities Affecting Cognition: [Sleep disorders, endocrine/metabolic, autoimmune, chronic pain, substance use with relevance to cognition and testing validity]
• Current Medications Impacting Cognition/Validity: [Relevant medications with recent changes]
• Language/Cultural/Sensory/Motor Factors: [Primary language, interpreter needs, hearing/vision/motor limitations relevant to test selection]

Prior Treatments and Response: [Medication trials, psychotherapy, rehabilitation, cognitive supports; response and residual deficits; if baseline before planned intervention such as surgery or chemotherapy, specify]

Objective Findings to Date: [Neurologic exam highlights; cognitive screening scores with interpretation caveats; imaging and labs; school/work records] (If pending or unavailable, note explicitly)

Records Reviewed and Attachments

• Records Reviewed in Preparing This Request:
  • [Referring provider note/order with date]
  • [Relevant specialty notes with dates]
  • [Imaging reports with dates]
  • [Other diagnostic studies with dates]
  • [Prior neuropsychological/psychological testing reports with dates]
  • [School records/IEP/504 with dates, if applicable]
• Records Attached with Submission: [List with dates]
• Records Requested but Not Yet Received: [List with dates requested and expected receipt] (If none pending, state "None")

Prior Testing and Non-Redundancy Justification

(If prior neuropsychological testing exists, complete the following. If no prior testing, state "No prior formal neuropsychological testing documented" and omit the bullets.)

[Date(s) and broad findings of prior testing without raw data]

• Changes Since Prior Testing: [New neurologic event, material functional decline, or treatment failure prompting reassessment]
• Non-Redundancy Statement: [Why current testing is not duplicative and is necessary to address new or remaining decision targets]

Proposed Testing Plan

• Domains to Assess: [Attention/processing speed; learning/memory; executive functions; language; visuospatial skills; motor/sensory; mood/personality/behavioral regulation as applicable]
• Approach and Setting: [Clinician-administered / technician-administered / both]; in-person
• Validity Assessment: Performance and symptom validity will be assessed as clinically indicated.
• Accommodations: [Interpreter; bilingual administration; sensory accommodations; extended time; breaks] (If none needed, state "None anticipated")
• Test Selection: [If payer requires specific names, list representative validated measures by domain; otherwise state "Validated measures will be selected based on referral question, demographic factors, and clinical presentation."] (Do not include test items, stimuli, or scoring keys.)
• Security Statement: Secure test materials, item content, and scoring keys are not included per psychometric and copyright standards; a narrative summary of findings will be provided in the final report.

Requested Codes and Time Allocation

(Include only applicable codes based on staffing model used.)

CPT Code	Description	Units/Time Requested	Performer
96116	Neurobehavioral status exam, first hour	[Number of hours]	Neuropsychologist
96121	Neurobehavioral status exam, each additional hour	[Number of hours]	Neuropsychologist
96138	Neuropsych test administration/scoring by technician, first 30 min	[Number of 30-min units]	Technician
96139	Neuropsych test administration/scoring by technician, each additional 30 min	[Number of 30-min units]	Technician
96136	Test administration/scoring by psychologist, first 30 min	[Number of 30-min units]	Neuropsychologist
96137	Test administration/scoring by psychologist, each additional 30 min	[Number of 30-min units]	Neuropsychologist
96132	Neuropsych testing evaluation services, first hour	[Number of hours]	Neuropsychologist
96133	Neuropsych testing evaluation services, each additional hour	[Number of hours]	Neuropsychologist

Total Time Justification: [Brief justification referencing complexity factors: multiple differential diagnoses, medical comorbidity, bilingual assessment needs, validity testing, records review volume, or need for detailed feedback and care coordination]

Provider Qualifications

[Rendering provider name], [degree/credentials], is licensed in [state(s)] with specialty training in clinical neuropsychology. [Board certification status, if applicable.] (If technician involvement is used, include: "Technician services are performed under direct supervision consistent with CPT and payer policy.") Interpretation, integration, and the final report are performed by the qualified clinician.

Expected Impact on Diagnosis and Management

• Diagnostic Outputs: [Differential clarification; severity and domain pattern characterization]
• Functional Recommendations: [Work/school accommodations; safety/driving guidance; return-to-work/return-to-play; independent living supports; capacity considerations]
• Treatment Recommendations: [Rehabilitation referrals; medication adjustments; psychotherapy focus; caregiver education/supports]
• Change-in-Management Statements: [Explicit decisions to be informed by results, e.g., differentiate neurodegenerative process vs psychiatric/sleep/medication effect; inform referral decisions; establish baseline for monitoring; guide capacity/safety determinations]

Attestation and Contact Information

I attest that the information provided is accurate and based on available records and clinical evaluation. Testing will be targeted to the referral question using validated measures, and redundant assessment will be avoided.

Rendering Clinician Signature: _________________________ Date: ____________

Ordering Clinician Signature: _________________________ Date: ____________ (Include if required by payer)

Primary Contact for Peer-to-Peer: [Name, direct phone, availability]