Psychological/Neuropsychological Testing Request (All information requested on this form must be complete. Missing data may result in authorization delay.) • Submission of this information by fax or phone does not constitute authorization of services. Blue Cross of Idaho’s Healthcare Operations department will notify you of their decision by fax, mail, phone or portal. • Authorization period may not exceed one month without review of medical records. If medical necessity justifies special handling, please include an explanation. • All psychological testing requests must include a diagnostic assessment completed within the last 30 days by a behavioral health professional as well as at least one validated symptom inventory or rating scale. Your request will not be processed without this documentation. • For questions regarding this form, please call 208-331-7535 or 800-743-1871. • Submit all elective prior authorization requests at least 10 days prior to the scheduled date of service. • If the request is URGENT please check here: q Reason for Urgent: ______q Behavioral Health: Fax 208-387-6840 PLEASE PRINT OR TYPE ONLY

Requesting Provider: Provider ID: Date:

Office Address: Tax ID Number:

Contact Person: Phone: Fax:

Patient Name: Enrollee ID: Date of Birth:

Testing Provider Information:

Name/Credentials: Provider ID:

Address:

Email address: Phone: Fax:

Service Request

Request Type: q Psychological q Neuropsychological

Number of units requested by CPT Code: PT: 96105:____ 96125:____96110:____ 96112:____ 96113:____ 96127:____ 96130:____ 96131:____ 96136:____ 96137:____ 96138:____ 96139:____ NPT: 96132:____ 96133:____ Automated: 96146:____

Has testing been completed previously? q Yes q No If Yes, date completed? ______

Indicate number of units requested for neuropsychological testing:

Indicate number of units requested for psychological testing:

List of tests to be administered:

Psychological Evaluation and Treatment

Reason for testing:

ICD 10 Diagnostic Code with description(s):

Have symptom inventories or rating scales been completed? q Yes q No List rating scales/inventories completed: Has a Diagnostic Interview/Evaluation (90791 or 90792) been completed? q Yes q No If Yes, date of interview: Has information been requested from behavioral health providers? q Yes q No If Yes, date of request/interview: Has collateral information been sought from family members? q Yes q No Explain: Any current substance use? q Yes q No If Yes, date of last use:

3000 E. Pine Ave. • Meridian, Idaho 83642 • 208-345-4550 Mailing Address: P.O. Box 7408 • Boise, ID 83707-1408 © 2019 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association Form No. 12-123 (09-19) Medical Evaluation and Treatment

Has information been requested from Medical providers? q Yes q No If Yes, with whom? ______

Date of request/interview: ______

Has the member been diagnosed with/suspected to have any of the following conditions?: q Amnesia q Dementia q Meningitis q Altered Consciousness q Encephalitis q Neurotoxin Exposure q Anoxic/Hypoxic Injury q Epilepsy q Premature q Autism q Head Injury q Radiation-Induced Injury q Brain Tumor q Language Disorder q Seizure Disorder q Cognitive Impairment q Multiple Sclerosis q Traumatic Brain Injury

If Yes, has it been suspected, confirmed, or diagnosed by imaging or other means? q Yes q No Date: For conditions selected above please indicate the date of onset: Current Psychotropic medication prescribed, dose and date began:

Patient History

History of Client (presenting problem with summary of psychosocial and medical information):

What is the question to be answered by testing that cannot be determined by a diagnostic interview, review of medical/behavioral records or second opinion?

How will test results be used to determine/modify treatment or evaluate response to treatment?

Are there any other psychological or medical explanations for current behavior/symptoms not addressed previously?

Signature of Psychologist with credentials: Date:

Form No. 12-123 (09-19) Assessment of Aphasia and Cognitive Performance Testing 96105 Diagnostic Aphasia Examination) with interpretation and report, per hour 96125 Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of a qualified health care professional’s time, both face-to- face time administering tests to the patient and time interpreting these test results and preparing the report Developmental/Behavioral Screening and Testing 96110 Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument 96112 Performed), by physician or other qualified health care professional, with interpretation and report; first hour 96113 Each additional 30 minutes (List separately in addition to code for primary procedure) 96127 Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument Psychological/Neuropsychological Testing Neurobehavioral Status Exam 96116 By physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour 96121 Each additional hour (List separately in addition to code for primary procedure) Test Evaluation Services 96130 First hour 96131 Each additional hour (List separately in addition to code for primary procedure) 96132 First hour 96133 Each additional hour (List separately in addition to code for primary procedure) Test Administration and Scoring 96136 Two or more tests, any method, first 30 minutes 96137 Each additional 30 minutes (List separately in addition to code for primary procedure) 96138 Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes 96139 Each additional 30 minutes (List separately in addition to code for primary procedure) Automated Testing and Result 96146 Psychological or neuropsychological test administration, with single automated instrument via electronic platform, with automated result only

Form No. 12-123 (09-19)