Conversational Style: Will My Insurance Cover Mental Health Testing?
If you’re considering a mental health or psycho-educational evaluation for yourself or your child, one of your first questions might be, “Will my insurance cover this?” The answer can be complicated, but understanding your options can save you stress—and money.
Understanding What Insurance Covers
Insurance may cover certain types of mental health evaluations, but it depends on your plan and the reason for the assessment. In general, insurance is more likely to cover an evaluation if it is considered “medically necessary.” This means the evaluation is needed to diagnose or treat a mental health condition.
What Counts as Medically Necessary?
An evaluation is typically considered medically necessary if it is used to:
- Diagnose a mental health condition (like anxiety, depression, ADHD)
- Determine the right treatment plan
- Monitor the progress of an existing condition
However, evaluations for educational purposes—like testing for learning disabilities or giftedness—are usually not covered. These are often considered “educational” rather than “medical” needs.
Step 1: Check Your Insurance Benefits
Start by looking at your insurance card to find the customer service phone number. Call and ask:
- Does my plan cover psychological testing or neuropsychological testing?
- Are there specific conditions that must be met (like a referral)?
- Do I need pre-authorization (approval before testing)?
- What is my deductible, copay, or coinsurance for mental health services?
Step 2: Get a Referral (If Needed)
Some insurance plans require a referral from your primary care physician before they will cover a mental health evaluation. If your plan has this requirement, schedule an appointment with your doctor and explain your concerns.
Step 3: Pre-Authorization
If your insurance requires pre-authorization, your clinician will need to submit paperwork explaining why the evaluation is medically necessary. This might include a brief summary of symptoms, a list of tests being used, and how the results will guide treatment.
Step 4: Out-of-Pocket Costs
Even with insurance, you may have some out-of-pocket costs. This can include:
- Your deductible (the amount you must pay before insurance starts covering costs)
- A copay (a set fee per visit)
- Coinsurance (a percentage of the cost)
Make sure you understand your financial responsibility before you begin testing.
Step 5: Out-of-Network Providers
If you choose a clinician who is not in your insurance network, you may still have options. Some plans offer “out-of-network” benefits, where they will reimburse part of the cost. You will usually need to pay the full cost upfront and submit a claim to your insurance for partial reimbursement.
Step 6: Keep Detailed Records
Save all paperwork, including:
- Your insurance benefit summary
- Referral letters (if needed)
- Pre-authorization approval
- Receipts or invoices for payments
If your insurance denies coverage, you may have the right to appeal. Keeping detailed records will help you make your case.
Professional Style: Navigating Insurance and CPT Codes for Assessments
Insurance coverage for psychological and neuropsychological evaluations is a complex area influenced by medical necessity, provider network status, and payer-specific policies. This article provides a clinical overview of best practices for navigating insurance coverage for mental health evaluations.
Medical Necessity Criteria
For an evaluation to be covered, it must be deemed medically necessary. This means:
- The evaluation is used to diagnose, treat, or monitor a mental health condition.
- It is supported by a physician or licensed mental health provider’s recommendation.
- It is not solely for educational purposes (e.g., school placement, gifted testing).
Commonly Covered Evaluations
Insurance is more likely to cover evaluations for:
- ADHD (attention and focus concerns)
- Anxiety and depression (emotional regulation)
- PTSD (trauma history)
- Bipolar disorder (mood swings)
- Cognitive decline (memory issues, dementia)
Procedures and CPT Codes
Clinicians use Current Procedural Terminology (CPT) codes to bill insurance for services. Common CPT codes for assessments include:
- 96130: Psychological testing (first hour)
- 96131: Psychological testing (additional hours)
- 96132: Neuropsychological testing (first hour)
- 96133: Neuropsychological testing (additional hours)
- 96136: Test administration by technician (first 30 minutes)
- 96137: Test administration by technician (additional 30 minutes)
Clinicians must accurately document the time spent on testing, scoring, and report writing.
Pre-Authorization and Documentation
Many insurance plans require pre-authorization for psychological evaluations. This means that the clinician must submit documentation explaining:
- The symptoms or concerns being assessed
- The types of tests to be used
- The expected benefit of the evaluation
Pre-authorization helps ensure that the evaluation meets the insurer’s criteria for medical necessity.
Network Status and Billing
Coverage may vary depending on whether the provider is in-network or out-of-network:
- In-Network: The provider has a contract with the insurance company, which often means lower costs for the patient.
- Out-of-Network: The patient may be responsible for a higher percentage of the cost, or may need to pay upfront and seek reimbursement.
Understanding Deductibles and Coinsurance
Patients should be aware of their insurance plan’s deductible (the amount they must pay before coverage begins) and coinsurance (the percentage of the cost they must pay even after the deductible is met).
Denied Claims and Appeals
If insurance denies coverage, patients have the right to appeal. This process typically involves:
- Submitting a letter explaining why the evaluation is medically necessary
- Providing supporting documentation from the clinician
- Following the insurance company’s appeal process
Best Practices for Clinicians
To maximize the likelihood of insurance coverage:
- Obtain pre-authorization when required
- Use clear, accurate CPT codes
- Document medical necessity in the patient’s record
- Communicate with patients about their financial responsibility
Reporting and Recommendations
Clinicians should provide patients with a clear explanation of coverage, including any out-of-pocket costs. Reports should also clearly state the purpose of the evaluation, the tests used, and how the results will guide treatment.
SubRosa Mental Services provides a client-forward approach to helping individuals, businesses, and children by offering Comprehensive Psychological & Psycho-Educational Evaluations, life coaching and emotional support animal assistance. Reach out today to find out more.
