Texas Medicaid (managed care plan guideline) psychological testing coverage: codes, limits and prior authorization
By Javier Alvarez · Updated · 1 min read
1 row: Medicaid (by state) · Texas. Public policy, not the member's benefits.
Texas Medicaid (managed care plan guideline)
Texas Children's Health Plan policy 6673, which points to the Texas Medicaid provider manual · Texas
| 96130 | Limited (psychological testing evaluation, first hour, within 8 hours per client per calendar year, more with prior authorization) [1] |
|---|---|
| 96131 | Limited (add-on, each additional hour, within 8 hours per client per calendar year, more with prior authorization) [1] |
| 96132 | Limited (neuropsychological evaluation, first hour, within 8 hours per client per calendar year, more with prior authorization) [1] |
| 96133 | Limited (add-on, each additional hour, within 8 hours per client per calendar year, more with prior authorization) [1] |
| 96136 | Limited (test administration and scoring, first 30 minutes, within 8 hours per client per calendar year, more with prior authorization) [1] |
| 96137 | Limited (add-on, each additional 30 minutes, within 8 hours per client per calendar year, more with prior authorization) [1] |
| Where it applies | The plan reviews psychological, neurobehavioral and neuropsychological testing billed outside the limits in the Texas Medicaid Provider Procedures Manual behavioral health handbook. [1] |
| Diagnoses | Medical necessity can be shown when testing is needed for a differential diagnosis that interview and brief rating scales cannot settle. [1] |
| Visit limits | Testing is limited to four hours per client per day and eight hours per client per calendar year. More testing needs prior authorization with clinical documentation. [1] |
| Prior authorization | A request over the limit must list current DSM diagnoses, the type of testing and procedure codes, the rationale and symptoms, and previous testing history and results. [1] |
| Also | Routine testing at facility admission is not considered medically necessary. Testing for legal, custody or placement purposes is not covered unless court ordered, and school-requested testing is not generally covered. [1] |
What Texas Medicaid (managed care plan guideline)'s documents say
The table above has every field we found for Texas Medicaid (managed care plan guideline), with numbered sources. In short:
- Prior authorization. A request over the limit must list current DSM diagnoses, the type of testing and procedure codes, the rationale and symptoms, and previous testing history and results.
- Visit limits. Testing is limited to four hours per client per day and eight hours per client per calendar year. More testing needs prior authorization with clinical documentation.
- Where it applies. The plan reviews psychological, neurobehavioral and neuropsychological testing billed outside the limits in the Texas Medicaid Provider Procedures Manual behavioral health handbook.
- Codes. 96130, 96131, 96132, 96133, 96136 and 96137 are limited.
Other psychological testing rows for Texas
Medicare, Novitas (AR, CO, DE, DC, LA, MD, MS, NJ, NM, OK, PA, TX).
Check Texas Medicaid (managed care plan guideline)'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 Texas Medicaid (Texas Children's Health Plan) with every other payer we checked.