Please help me not screw up in asking about coverage for neuropsych eval

[Anonymous]

After discussions with our son's life-long pediatrician and having a 45-minute phone consultation with a reputable neuropsychology practice, my husband and I have agreed that we want to schedule a neuropsychological evaluation for our son. It will cost $3500 and if we have to pay for the entire thing out of pocket, we will. However, I want to see if my insurance will cover any of it. I have the 200-page Group Contract that details covered benefits and exclusions.

I couldn't find anything in the contract that excludes coverage under the Exclusions section, and under the Benefits section, within the Mental Health and Substance Abuse Services subsection I found "Outpatient Psychological and Neuro-Psychological Testing for Diagnostic Purposes."

Because the practice does not take insurance, if I do receive any coverage it would be considered out-of-network, meaning I'd have to satisfy my deductible first. Fine. And I also understand that I'll have to submit any claims myself.

In talking with the practice, they gave me a specific procedure code (#96101) and told me to call my insurer (CareFirst) and ask if "I have out-of-network coverage for neuropsych evaluation billed under 96101."

Seems simple enough, but does anyone have any advice or words of caution before I make the call? I don't want to say the wrong thing or just accept a simple "no." Also, do I just call the "Member Service" number on the back of my card or should I call the number listed for "Mental Health/Substance Abuse"?

Thanks for humoring me.

[Anonymous]

Assuming you have a PPO plan that doesn't require a primary care physician referral, and your plan has decent out of network benefits, I'd call member services. They'll refer you to mental health if that's wrong.

Because you have the code it should be a simple yes / no.

If they ask more, I would say you are seeking the evaluation due to concerns about anxiety and attention. Don't say anything about learning disabilities.

In our case, we got about $650 back out of a $3800 bill from CareFirst PPO plan. Anything that was an 'academic' concern was not reimburseable at all.

[Anonymous]

I'm not suggesting lying about learning disabilities. Just only share that if asked directly. I wouldn't lead with it

[Anonymous]

OP, what I remember from when I did this process for my son with Blue Cross Blue Shield FEP, was that the testing was covered if the reason for the testing was a medical in nature. But the same testing was not covered if it was for academic reasons. So psychological tests because of concern for conditions like ADHD or bipolar disorder was covered, but similar tests to investigate causes of poor reading would not be covered.

[Anonymous]

Thank you, PPs. Very helpful. -OP

[Anonymous]

Our psychologist gave us an itemized bill that I submitted. Most wasn't covered but they did reimburse for part of it.

[Anonymous]

Can you find one covered by your insurance?

[Anonymous]

Absurdly, coverage is going to depend on the ultimate diagnosis since, like PPs have said, you won't get coverage for anything deemed academic. So if your concerns were 100% about attention, but it turns out that dyslexia was causing the attention problems (which happens, that's the point of comprehensive evaluations), then you won't get reimbursed. But if your concerns were with reading, but it turned out to be ADHD, you would get something back.

It's like if you went to the pediatrician because your child had a sore throat and fever, but the strep test was only covered if it turned out to be positive.

[Anonymous]

OP, 96101 falls under Central Nervous System Assessments/Tests (eg, Neuro-Cognitive, Mental Status, Speech Testing). It specifically refers to:
Pscyhological testing (includes Psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the psychologist's or physician't time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.

FYI I took this verbatim from the 2017 CPT book put out by the AAPC (basically a coding bible).

If, for some chance Carefirst says they don't cover under this procedure code, ask them which procedure codes they cover for neuropsych testing.

[Anonymous]

I heart all you PPs. Thank you so much for all the help and useful info. I can't tell you how much I appreciate it. --OP

[Anonymous]

OP here. One follow-up. My carefirst contract says "Except for Emergency Services, Urgent Care, and follow-up care after emergency surgery, benefits will not be provided for any service(s) provided to a Member by Non-Contracting Physicians or Non-Contracting Providers, unless written prior authorization is specifically obtained from CareFirst BlueChoice."

So, if I do determine that the neuropsych testing is covered (to some extent) it seems I must get written pre-authorization before we begin testing/treatment. I've never done that before. I'll certainly research what I have to do, but if anyone has gone through the process of getting pre-authorization from their insurer (CareFirst specifically would be great) and can tell me what's involved, I'd appreciate it. Just like my OP post, any advice or cautions about requesting preauthorization? I know now not to mention "education."

And PP who explained the weird circumstance where a coverage determination isn't made until after the diagnosis, thank you for this heads up. Thanks.

[Anonymous]

Anonymous wrote:OP here. One follow-up. My carefirst contract says "Except for Emergency Services, Urgent Care, and follow-up care after emergency surgery, benefits will not be provided for any service(s) provided to a Member by Non-Contracting Physicians or Non-Contracting Providers, unless written prior authorization is specifically obtained from CareFirst BlueChoice."

Sounds to me like you need prior authorization for out-of-network or "non-preferred" Providers?

[Anonymous]

Anonymous wrote:

Anonymous wrote:OP here. One follow-up. My carefirst contract says "Except for Emergency Services, Urgent Care, and follow-up care after emergency surgery, benefits will not be provided for any service(s) provided to a Member by Non-Contracting Physicians or Non-Contracting Providers, unless written prior authorization is specifically obtained from CareFirst BlueChoice."

Sounds to me like you need prior authorization for out-of-network or "non-preferred" Providers?

Agree.

If you had this testing done with an in-network hospital (e.g. Children's or KKI) then whatever benefit they give you for that code would be covered.

If you want to go out of network or to an insurer who doesn't take insurance at all, you need prior authorization or they may not cover anything, regardless of the treatment code. So if you lived somewhere with no in-network providers to perform a service, they may grant permission for you to use a portion of the benefit with an out of network provider. But in this case, I think it's unlikely.

Have you used out of network providers for any other health care service for any family members with this insurance?

[Anonymous]

op, we have carefirst (blue cross blue shield FEP)
and KKI is a participating provider, so we had it covered there without any finagling.

[Anonymous]

Anonymous wrote:Assuming you have a PPO plan that doesn't require a primary care physician referral, and your plan has decent out of network benefits, I'd call member services. They'll refer you to mental health if that's wrong.

Because you have the code it should be a simple yes / no.

If they ask more, I would say you are seeking the evaluation due to concerns about anxiety and attention. Don't say anything about learning disabilities.

In our case, we got about $650 back out of a $3800 bill from CareFirst PPO plan. Anything that was an 'academic' concern was not reimburseable at all.

We had the same experience with CareFirst.