Prior Authorization Request (Psychological Testing)

Date: [Date of submission]

To: [Payer/utilization management department name, address, fax number, and/or portal routing details]

Re: Prior Authorization Request – Psychological Testing

Patient: [Full name], DOB: [Date of birth], Member ID: [Member ID], Group ID: [Group ID], Plan: [Plan type] (If member ID is unavailable, state: "Member ID not available at time of submission; will provide upon request.")

Requesting Provider: [Provider name], [Credentials], NPI: [NPI], Tax ID: [Tax ID], [Service location address/phone/fax]

Referring Clinician: [Name], [Credentials], NPI: [NPI] (Include only if different from requesting provider; otherwise omit this line.)

Requested Service Dates: [Start date] – [End date]

Request Summary

Requested Service	[Psychological testing / Neuropsychological testing]
Primary Clinical Questions	[Clinical question 1 tied to a specific management decision] [Clinical question 2] [Clinical question 3] (Include 1–3 concise, answerable questions.)
Working Diagnoses	[Diagnosis list with ICD-10 codes] (Use "suspected" or "provisional" if not yet confirmed.)
Differential Diagnoses	[Rule-out conditions contributing to diagnostic ambiguity]
Functional Impairment Summary	[Concrete impairment example 1 with severity anchor] [Concrete impairment example 2 with severity anchor] [Concrete impairment example 3 with severity anchor] (Include 2–4 bullets with real-world examples.)
Key Prior Interventions and Response	[Intervention 1, dose/duration, response/limitations] [Intervention 2, response/limitations] [Intervention 3, response/limitations] (Include 2–5 bullets.)
Estimated Total Testing Hours	[Total hours] – [Brief rationale linking domains, complexity, and interpretation time]
How Results Will Change Management	[If finding X → then action Y] [If finding X → then action Y] [If finding X → then action Y] (Include 3–6 specific decision points using "If X → then Y" format.)

Requested CPT Codes and Units

Code	Description	Units	Est. Time	Purpose in This Case
[CPT code]	[Description]	[Units]	[Time]	[Case-specific purpose]
[CPT code]	[Description]	[Units]	[Time]	[Case-specific purpose]
[CPT code]	[Description]	[Units]	[Time]	[Case-specific purpose]

Clinical Context and Referral Questions

[Narrative describing reason for referral, who initiated it, onset/duration/course of symptoms, severity and frequency of key symptoms, precipitating factors, and relevant risk factors.] (4–10 sentences. Clearly distinguish information sources as follows:)

Patient-reported: [Symptoms, timeline, subjective concerns, functional difficulties as described by patient.]

Collateral-reported: [Information from family, school, employer, or other providers.] (Include only if collateral was obtained.)

Clinician-observed: [Behavioral observations, mental status findings, in-session performance, discordant data points.]

Prior screenings/brief assessments: [Rating scales or brief screens completed and why they are insufficient to resolve the clinical questions.]

Specific Referral Questions:

• [Question 1: Answerable by testing and tied to a specific treatment decision]
• [Question 2]
• [Question 3]

(Avoid broad phrasing such as "evaluate for mental health concerns" without specifying the decision that depends on results.)

Relevant History

(Include only history that directly supports medical necessity or explains diagnostic complexity. Omit subsections with no relevant information.)

Psychiatric History

• [Prior diagnoses, hospitalizations, treatment history relevant to current presentation]

Medications

• [Current and past medications with dose ranges, duration, response, and adverse effects]

Medical/Neurologic History

• [TBI, seizures, stroke, sleep disorders, metabolic conditions, or other factors relevant to cognition or mood]

Developmental/Educational History

• [Milestones, learning concerns, IEP/504 history, prior academic testing]

(Include only if relevant to differential diagnosis.)

Substance Use

• [Pattern, quantity, temporal relation to symptoms, treatment history]

Family Psychiatric History

• [Relevant familial conditions if pertinent to risk or interpretation]

Occupational/Social Context

• [Role demands contributing to impairment or safety concerns]

(If records were requested but not yet received, state: "Records requested from [source]; not yet received.")

Diagnoses and Differential

Current Working Diagnoses: [Diagnosis 1 (ICD-10)]; [Diagnosis 2 (ICD-10)] (Use "provisional" or "suspected" as appropriate.)

Differential/Rule-out Diagnoses:

• [Rule-out diagnosis 1]: [Overlapping symptoms creating ambiguity]; [Why interview/rating scales are insufficient]; [What testing will determine]
• [Rule-out diagnosis 2]: [Overlapping symptoms]; [Limitations of current methods]; [What testing will clarify]
• [Rule-out diagnosis 3]: [Overlapping symptoms]; [Limitations of current methods]; [What testing will clarify]

Functional Impairment

(Provide concrete, real-world examples. Avoid vague statements like "significant impairment.")

• Work/occupational: [Errors, discipline, absenteeism, productivity issues with severity]
• Academic: [Grades, incomplete work, accommodation needs with severity]
• Daily living: [Medication management, finances, driving, scheduling with safety implications]
• Social: [Conflict, isolation, relationship strain with severity]
• Safety: [Impulsivity, self-harm risk, risky behaviors with context and frequency]
• Treatment adherence: [Cognitive or psychiatric barriers to adherence]

(Include only applicable domains.)

Prior Evaluations and Interventions

• Prior evaluations: [Psychiatric, medical, or neurologic evaluations with key findings and limitations]
• Screening tools: [Tools used, scores, and limitations for current questions]
• Psychotherapy: [Type, frequency, duration, response]
• Medication trials: [Agents, doses, durations, responses, adverse effects]
• Accommodations: [School/work strategies attempted and why insufficient]
• Prior testing: [Date, summary of findings, why retest is needed]

Duplication avoidance: Prior testing reviewed; requested testing targets unanswered questions and/or change in clinical status.

Medical Necessity Justification

1. Statement of necessity: Testing is medically necessary to answer [specific referral questions] that cannot be resolved by clinical interview or observation alone.
2. Why now: [Timing driver: new/worsening symptoms, stalled treatment, pre-treatment decision point, safety/functional decline, conflicting data]
3. Why other methods are insufficient: [Limitations of rating scales, brief screens, and interview in this case due to confounding comorbidity, atypical presentation, conflicting history, or validity concerns]
4. Why this scope: [Justification for requested hours and domains linked to referral questions and functional impairment] (Avoid "standard battery" language; individualize rationale.)

Requested Testing Scope and Plan

Domains to evaluate: [Attention/executive function], [Processing speed], [Memory/learning], [Mood/anxiety], [Personality/behavioral functioning], [Adaptive functioning], [Symptom validity] (Tailor to referral questions; include only relevant domains.)

Information sources: Record review, clinical interview, collateral questionnaires, standardized measures, behavioral observations.

Administration: [Licensed psychologist will conduct clinical interview, test selection, integration, and reporting. Trained technician/psychometrist will administer and score standardized tests under psychologist supervision.] (Modify based on actual staffing model.)

Instrument selection: Battery will be individualized; specific measures may be adjusted based on initial interview, validity considerations, language needs, and disability accommodations. (If payer requires named instruments, list representative measures while noting that clinically appropriate substitutions may be necessary.)

Deliverables: Integrated interpretive report addressing referral questions; feedback session; communication to referring clinician.

How Results Will Change Management

(Use "If X → then Y" format. Be specific about downstream actions.)

• [If finding X is confirmed → then specific treatment action Y]
• [If finding X is confirmed → then specific treatment action Y]
• [If finding X is confirmed → then specific treatment action Y]
• [If finding X is confirmed → then specific treatment action Y]
• [If finding X is confirmed → then specific treatment action Y]

(Include 3–8 decision points. Avoid vague statements like "results will guide treatment" without specifying what guidance will occur.)

Urgency and Safety Factors

(Include only if urgency factors exist; otherwise omit this section entirely.)

• Review type requested: [Routine / Expedited] – [Rationale if expedited]
• Safety concerns: [Suicide/self-harm risk, violence risk, grave disability, cognitive safety concerns such as driving or medication mismanagement]

Attestations

• Testing is requested for clinical/medical management purposes, not solely for educational placement, employment, custody/forensic, or disability determination.
• A clinical interview/evaluation has been completed and informed this request.
• Prior relevant testing and records have been reviewed to prevent duplication.

Closing

If additional information is needed, I welcome a peer-to-peer review.

Peer-to-peer contact: [Name], [Direct phone], [Fax]

Sincerely,

[Provider name], [Credentials]
[License type and state]
NPI: [NPI]
[Practice/Organization name]
[Address] | [Phone] | [Fax]

Attachments/Records Reviewed

(Optional. List attachments or summarize records reviewed.)

• [Referral documentation]
• [Relevant progress notes or problem list]
• [Prior testing reports]
• [Rating scales or screening results]