Pennsylvania Medicaid (PerformCare and Philadelphia CBH) psychological testing coverage: codes, limits and prior authorization
By Javier Alvarez · Updated · 1 min read
1 row: Medicaid (by state) · Pennsylvania. Public policy, not the member's benefits.
Pennsylvania Medicaid (PerformCare and Philadelphia CBH)
PerformCare testing request form (Capital, Franklin and Fulton counties) and Philadelphia CBH bulletin 24-15 · Pennsylvania
| 96130 | Limited (needs prior authorization at PerformCare (Capital, Franklin and Fulton counties)) [1] |
|---|---|
| 96131 | Limited (needs prior authorization at PerformCare (Capital, Franklin and Fulton counties)) [1] |
| 96132 | Limited (needs prior authorization at PerformCare (Capital, Franklin and Fulton counties)) [1] |
| 96133 | Limited (needs prior authorization at PerformCare (Capital, Franklin and Fulton counties)) [1] |
| 96136 | Limited (needs prior authorization at PerformCare (Capital, Franklin and Fulton counties)) [1] |
| 96137 | Limited (needs prior authorization at PerformCare (Capital, Franklin and Fulton counties)) [1] |
| 96138 | Limited (needs prior authorization at PerformCare (Capital, Franklin and Fulton counties)) [1] |
| 96139 | Limited (needs prior authorization at PerformCare (Capital, Franklin and Fulton counties)) [1] |
| Visit limits | PerformCare will not authorize 96130 and 96132 at the same time. It authorizes whichever matches the testing request. Test review with the member is limited to 1 hour maximum. [1] |
| Prior authorization | PerformCare says prior authorization is required. It issues the approved units under 96130 for psychological testing or 96132 for neuropsychological testing, and providers bill the combination of codes. [1] |
| Managed care plans | Philadelphia's Community Behavioral Health changed its rule effective June 10, 2024: it requires preauthorization for 96130 and 96131, and for 96136 and 96137, using its own request form. [2][2] |
| Also | PerformCare only issues the authorization after the provider mails or faxes the testing results. Testing for educational, vocational or legal purposes, or routine for treatment entry, is not authorized. [1] |
What Pennsylvania Medicaid (PerformCare and Philadelphia CBH)'s documents say
The table above has every field we found for Pennsylvania Medicaid (PerformCare and Philadelphia CBH), with numbered sources. In short:
- Prior authorization. PerformCare says prior authorization is required. It issues the approved units under 96130 for psychological testing or 96132 for neuropsychological testing, and providers bill the combination of codes.
- Visit limits. PerformCare will not authorize 96130 and 96132 at the same time. It authorizes whichever matches the testing request. Test review with the member is limited to 1 hour maximum.
- Codes. 96130, 96131, 96132, 96133, 96136, 96137, 96138 and 96139 are limited.
Other psychological testing rows for Pennsylvania
Medicare, Novitas (AR, CO, DE, DC, LA, MD, MS, NJ, NM, OK, PA, TX).
Check Pennsylvania Medicaid (PerformCare and Philadelphia CBH)'s claim against the row
Before the claim goes out, compare it with the row above: the evaluation and administration codes pair the way the policy says, the hours fit any cap, the referral question is documented, and prior authorization covers the units. The psychological testing table compares Pennsylvania Medicaid (HealthChoices behavioral health) with every other payer we checked.