All Counties - Community Care Behavioral Health

Neuro/Psychological Testing Preauthorization Request
All Counties
Either the provider doing the referral for neuro/psychological testing or the provider doing the testing must complete this form.
However, the completed form must be reviewed and approved by the testing provider. Provide information allowed by applicable
state law. Authorization for testing will not be considered until all sections of this form are completed. To avoid potential
issues with reimbursement, testing is not to be initiated until authorization has been received.
Please send the completed form via fax to the following number per member contract:
Community Care Behavioral Health Organization (HealthChoices):
Allegheny (Pittsburgh Office) (Fax) 1-888-251-0087 North Central (Pittsburgh Office) (Fax) 1-866-294-3935
Carbon/Monroe/Pike (Tobyhanna Office) (Fax) 1-866-562-2405 Northeast (Moosic Office) (Fax) 1-866-284-9184
Chester (Exton Office) (Fax) 1-888-589-6559 York/Adams/Berks (Camp Hill Office) (Fax) 1-866-418-0366
Erie (Erie Office) (Fax) 1-855-892-8495 Lycoming/Clinton (Williamsport Office) (Fax) 1-855-473-2360
Blair (Holidaysburg Office) (Fax) 1-855-473-2359
Current Date Member Name: MA #:
Member County of Residence:
Member Date of Birth:
Does Member have a Primary Insurer other than Community Care? Yes No
Name of Primary Insurer:
Person/Agency Making Request for Testing: PCP Medical Specialty (Specify)
Psychotherapist Psychiatrist Parent
Referring Provider Information:
Testing Provider Information:
Name/Degree:
Address:
Name/Degree:
Address:
Phone #:
Fax #:
Code:
Phone #:
Fax #:
Contact Person
if Different than Above:
Current or Provisional DSM-IV
Description:
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What information is testing expected to
provide that cannot be determined by a
diagnostic interview, review of
psychological/psychiatric records, or a
second opinion?
How would results of testing affect the
treatment plan?
What are the current symptoms related
to the referral question?
What is the referral question to be
answered by testing?
Medical/Psychological Evaluation:
Has client had a diagnostic interview?
No
Yes
Date of interview:
Previous Psych Testing? No Yes When, Basic Focus,
and Results:
Medications Prescribed?
Anti-anxiety Agents
Anti-Parkinsonian
Anti-convulsants
Anti-psychotic
Agents
Anti-depressants
Sedatives/
Hypnotics
Anti-manic
Agents
NONE
Other:
Is member currently attending school? No Yes If Yes, where?
Is member currently abusing any substance? No Yes If Yes, Elaborate:
Requested Testing:
Psychological Testing
(Children/Adolescents) 5 Hours
Psychological Testing
Neuropsychological Testing
(Children/Adolescents) 7 Hours
Neuropsychological Testing
Date to be Administered:
Number of Hours Requested:
Names and Types of Tests: