How to Check Your Insurance Coverage for a Neuropsychological Evaluation

This process typically takes 15-20 minutes.

Neuropsychological evaluations are specialized assessments that help understand how a child learns, thinks, and behaves. Because they involve comprehensive testing by licensed psychologists, insurance coverage varies widely, and many plans have specific rules.

We recommend calling your insurance company to verify whether and how it will be covered.

Purpose: This guide will help you understand what to ask your insurance company before scheduling.

This guide is for informational purposes only. Insurance benefits and coverage determinations are made solely by your insurance company.

STEP 1: PREPARE — What You'll Need

Before you call, gather these items:

  • Your insurance card (front and back)
  • A pen and this guide to take notes
  • Your child's date of birth and member ID
  • About 15-20 minutes of uninterrupted time
STEP 2: CALL — Who to Ask For

Use the Member Services number on the back of your insurance card. Ask to speak with someone who handles:

  • Behavioral health benefits
  • Mental health benefits
  • Psychological testing benefits

Tip: It's okay to ask them to repeat information or to speak more slowly. Take your time.

SAMPLE SCRIPT — What to Say:

"Hi, I'm calling to check whether my insurance plan covers neuropsychological evaluations for my child, who is experiencing (e.g., learning, attention, or emotional) difficulties. The evaluation is to assess cognitive, learning, attention, emotional, or behavioral functioning, and to determine whether a medical or neurodevelopmental diagnosis is appropriate. Can I ask you a few questions?"

STEP 3: ASK — Questions Checklist

Here is a list of common questions to ask your insurance company. Check each box as you go:

1. Do I have coverage for neuropsychological evaluations for my child? You may need to say: "This evaluation is for diagnostic purposes to assess cognitive, learning, attention, emotional, or behavioral functioning."
2. Is a neuropsychologist considered a covered provider under my plan? If yes, ask whether out-of-network neuropsychologists are covered, and at what rate.
3. Do I need a referral or prior authorization? If yes: What is the process? Can it come from a pediatrician, psychiatrist, or another provider?
4. The following CPT (billing) codes are commonly used for neuropsychological evaluations. Ask if covered: a. 96116    b. 96132, 96133    c. 96136, 96137
5. Does the evaluation need to be medically necessary for it to be covered?
6. What diagnosis codes are required for coverage? Some plans only cover certain medical or mental health diagnoses.
Some plans limit or exclude coverage for evaluations related to ADHD, learning disabilities, or autism spectrum disorder.
7. What is my deductible, and how much of it has been met?
8. What is the co-insurance or reimbursement rate for out-of-network services?
9. Are there any limits to the number of hours or sessions covered for testing?
10. Will the evaluation be denied if learning or attention difficulties are the primary concern?
11. What documents do I need to submit for reimbursement? Examples: superbill, claim form, referral letter, letter of medical necessity.
12. How and where do I submit these and other documents (e.g., online portal, mailing address, or fax)?
STEP 4: RECORD — Keep Track of Your Call

Record-Keeping Tips

  • Get the name of the representative, date of the call, and a reference number if available.
  • Save all documents and correspondence with your insurance company.
  • It may take several weeks (or longer) for reimbursement. Keep checking your portal or follow up as needed.
STEP 5: FOLLOW UP — Important Notes & Next Steps

Important Notes

  • Neuropsychological testing is often only partially covered, or not at all, especially if considered "educational" in nature.
  • Private-pay or out-of-network options are often used when in-network coverage is unavailable or limited.
  • A letter of medical necessity from your pediatrician, primary care, or psychiatrist can improve the likelihood of approval.

You'll know your call was successful if you have:

  • ✓ A clear answer on whether neuropsych evaluations are covered
  • ✓ Information about your deductible and out-of-pocket costs
  • ✓ The representative's name and a reference number
  • ✓ Instructions on how to submit for reimbursement

Remember: Don't worry if you need to call back. Insurance can be confusing, and it's completely normal to need clarification. You're doing a great job advocating for your child.

If you need CPT codes or a superbill for your records, our office can provide these upon request.