Effective November 1, 2020, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will remove psychological and neuropsychological testing from prior plan approval (PPA). PPA will no longer be required for psychological and neuropsychological testing. This change aims to help reduce provider administrative time and allow for continued access to medically necessary services.
Medical Policy Adherence
With the removal of these services from PPA, Blue Cross NC trusts providers will continue to demonstrate adherence to medical policy, maintain proper utilization, and avoid inappropriate utilization for actions such as surgical clearance and repeat testing. To ensure proper utilization and medical adherence, we will monitor and review utilization. We use Milliman Care Guidelines (MCG) to evaluate medical necessity.
Members and CPT Codes included in this change
The removal of psychological and neuropsychological testing from PPA applies only to Blue Cross NC commercial membership at this time, including Fully Insured, IPP Home, IPP Host, and Administrative Services Only (ASO). The Federal Employee Plan (FEP) offered and administered by Blue Cross NC has not and will not require PPA. However, Medicare Advantage still requires PPA, as well as the State Health Plan (SHP) through Beacon Health Options when part of an inpatient stay.
The following codes will no longer require PPA for commercial members:
Psychological and/or Neuropsychological Testing Requirements
Psychological and/or neuropsychological testing are not a requirement for pre-surgical clearance for the following services (however there may be some circumstances where this testing is justified and meets medical necessity):
- As a requirement for pre-surgical clearance for services such as Bariatric Surgery -- only psychological evaluation is required, NOT testing
- As a requirement for pre-surgical clearance for services such as Spinal Cord and Dorsal Root Ganglion Stimulation -- only a psychological evaluation is required, NOT testing
- The patient has undergone careful screening, evaluation and diagnosis by a multi-disciplinary pain management team (including psychological as well as physical evaluation)
Psychological and neuropsychological testing is appropriate when:
- The information achieved by psychological or neuropsychological testing is not attainable through routine medical, neurologic, or psychological assessment.
- The results of proposed psychological or neuropsychological testing are judged likely to affect care or treatment of the patient.
- The testing is administered by a provider whose qualifications are appropriate for the level of testing required.
- The time (i.e. number of hours) for administration, scoring, interpretation, report preparation, and explanation of results reflects recognized norms for the type of testing being completed (e.g. 8 hours or fewer).
- The frequency of testing reflects recognized norms for the type of test being completed (e.g. one initial testing evaluation, followed by no more than one additional re-testing evaluation within 12-month period).
- The member is not using, in withdrawal, or recovering from chronic use of substances such as drugs and/or alcohol.
Please note, the removal of psychological and neuropsychological testing is subject to change at any time. To share feedback or ask questions, please contact BehavioralHealth@bcbsnc.com.