An Important Message about Blue Cross Blue Shield Insurance Coverage

The rules according to which Blue Cross Blue Shield of Massachusetts (BCBSMA) evaluates the need for, and authorizes, neuropsychological testing have changed, in most cases resulting in significant reductions in the benefits you are likely to receive under any of their plans. The most important thing to note is that prior authorization from BCBSMA is now required for all neuropsychological testing.

Procedurally, in determining the need for testing, BCBSMA will no longer rely solely upon direct referrals from pediatricians or primary care physicians. Using his portion of the form below, your doctor, as “requesting provider,” must first express his or her concerns about your child to us, as the prospective “testing provider,” and provide some history. At your intake, or clinical interview, one of our staff will carefully consider any relevant medical issues, your impressions and the doctor’s findings, arrive at a preliminary diagnosis and then, based upon that, complete our portion of the form and submit it to BCBSMA as now required.

Download the BCBSMA Neuropsychological Testing Request Form Here

This request will be reviewed by BCBSMA and approved or denied on the basis of “medical necessity,” as defined by a new, proprietary set of criteria they recently adopted. These standards are quite restrictive, greatly reducing both the number of testing hours likely to be authorized, and limiting the potential diagnoses for which testing is considered medically necessary. For example, testing primarily for educational purposes is not allowed, nor will diagnostic testing for ADHD be authorized, because according to the new criteria, it is not medically necessary.

We will try hard to optimize your insurance coverage for the services we provide and that your child needs and deserves. You can help us do that by providing as much information as possible prior to your intake appointment. Please download the “Neuropsychological Testing Request Form” above, provide it to your doctor and make sure that he or she completes and returns it to us promptly.

Without it, we cannot persuasively request prior authorization for testing from BCBSMA, and absent such authorization, which may take 4-6 weeks to obtain, we cannot proceed with your child’s evaluation, unless you assume full financial responsibility for it yourselves. In such cases, we will provide the documentation you will need to seek reimbursement from BCBSMA.

Another unfortunate consequence of these rule changes is that prior authorization has become almost impossible to obtain from out-of-state Blue Cross Blue Shield plans, which we therefore can no longer accept.

As always, we urge you, as their customer, to contact BCBSMA directly with any questions you have about your particular plan and the benefits it provides. In deciding to proceed with an evaluation, it is very important that you understand the limits of your coverage and potential personal exposure. NESCA regretfully can’t offer any guarantee that all or any part of our services will be covered.

Look Here for Instructions on How to Obtain Authorization for Testing