Does my health insurance plan cover the cost of a psychological evaluation?

The answer to this question depends on the health insurance plan you have selected.  Most insurance plans cover psychological evaluations.  However, many insurance plans require a prior authorization for this service, and most plans will also require that you meet your deductible, pay a co-pay, and/or pay co-insurance for the evaluation. 

Psychologist Appointments Covered by Insurance

The prior authorization process is meant to determine if a service is “medically necessary.”  Each insurance company has their own criteria to determine what comprises medical necessity.  If a prior authorization request is denied, you will typically receive a letter that states why the request was denied.  You will also be given a chance to appeal the decision.  The insurance company provides you with a number to call, and you can explain to the representative why you believe the evaluation would be impactful, or provide additional documentation that demonstrates the severity of current symptoms-thus supporting the concept that this service is medically necessary.  If the prior authorization request is approved, the insurance company will contact the psychologist and let him or her know that the evaluation is approved.  The insurance company will also provide the psychologist a list of CPT codes for billing purposes and will give the psychologist a limit of how many units or hours they can bill.  For example, common CPT codes used for psychological testing are 90791, 96130, 96131, 96136, and 96137.  The insurance company might approve 1 unit of a certain code, or they may approve 8 units of another code (depending on the intent of the code).  Once the psychologist receives this list of approved codes, he or she can proceed to scheduling the evaluation (or the psychologist may not accept the approved units for billing if he or she believes the insurance company did not approve enough units to cover the time needed to administer, interpret, and write the evaluation report).

If you would like to know how much you will be expected to pay for the evaluation, you should contact the customer service number on the back of your insurance card.  You can review the CPT codes that have been approved for the evaluation, and ask the customer service representative for the total cost of the evaluation (calculated by adding up the contracted rate for each of the approved CPT code units).  The representative can then tell you what part of the cost you would be responsible for paying.  You may be expected to meet the total cost of your deductible before the insurance company covers the cost of the service.  Every plan is different, but you will want to ask specifically if your deductible has been met, or how much you will need to pay before the deductible is met and the subsequent co-insurance cost. This will give you an accurate idea of what you will be responsible for paying.  Oftentimes, it can be confusing to hear that a service has been approved, and then receive a bill weeks to months later for a cost you did not expect. 

Lastly, if you have Medicaid insurance, you will not be expected to pay anything out of pocket for this evaluation.  You may still have to go through the prior authorization process depending on the type of evaluation that is being requested, but the cost of the evaluation is fully covered by Medicaid if it is approved.  In fact, it is illegal in the State of Colorado to require payment from a Medicaid recipient for a service that is covered by Medicaid.  E.g. Your psychologist/medical provider cannot send you a bill or ask you to make a payment for a service that is covered by Medicaid. 

Check out the approved insurances Brain & Body Integration accepts for all psychological evaluations performed in Colorado Springs and Denver. Contact one of our two offices to get all your other questions answered today.

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