MercyCare Health Plans and Mercy Physician Association
Prior Authorization for Outpatient Neuro-Psychological Testing
Please call the Quality Health Management Department at 800-752-3431 for instructions and the policy on submitting this form electronically.
Name:__________________________________________
MercyCare ID#:__________________ Effective Date__________
Group #:_____________________
Age: _______
Gender
MPA Only:
Member Request Yes
Physician Recommended
No
Yes
M
F
DOB_________
Plan:_________________
PCP:_______________________________________
Date of Last Physical:_________________________
No
Acute Brain Insult (Check all that Apply)
Anoxic/Hypoxic Brain Injury
Hx of Intracranial Surgery
Confirmed Neurotoxin Exposure
Cerebrovascular Accident
Encephalitis
Pervasive Developmental Disorder (Child/Adolescent)
Description of Injury:_____________________________________________________
Brain Damage Suspected/Diagnosed
Traumatic Brain Injury
Confirmed by Imaging
Hx of Head Injury with Loss of Consciousness/Post
Traumatic Amnesia
Date of Injury:___________________
Other Neurological Condition (Check all that Apply)
Brain Tumor in Remission/with Slow Progression
Dementia/Mild Cognitive Impairment Suspected/Diagnosed
Epilepsy and Cognitive Impairment Suspected/Demonstrated
Seizures (at least 1x/mo. and on optimal medication)
Neurosurgery Planned for Epilepsy Control
Adolescent Cerebral Palsy/Static Encephalopathy
Other
Multiple Sclerosis and Suspected/Demonstrated Cognitive
Impairment
Child/adolescent Hydrocephalis with stint placement
Testing History
(Adolescent) No Cognitive Impairment Suspected/Evident
(Adolescent) 1 previous episode of testing and no testing
(Child) Previous Testing Performed and Neurologic Deficit
within the last 12 months
Confirmed
(Child/Adolescent) At least 2 previous episodes of testing and
No Previous Neuropsychological Testing
no testing within the last 3 years
Unexpected change in symptoms within the last 4 months and
(Child) 1 previous episode of testing and no testing within the
no more than 1 testing episode in the last 12 months
last 6 months
Retesting planned to evaluate the response to new treatment
(Child/Adolescent) Language disorder suspected/diagnosed
and no more than 1 testing episode within the last 12 months
(Child) Epilepsy diagnosed and seizures at least 1 time per
Retesting planned to monitor rehab/functioning and no testing
month
within the last 6 months
Medication Review
Patient on Medication and Drug Side Effects Ruled out as Cause of Cognitive Impairment
Substance Abuse/Dependence and at Least 10 days Sobriety
No Medication/Substance Use
_______________________/_________________________
Referring Practitioner Print/ Signature
________________
________________________
Location
Phone Number
Acute Brain Insult
Child (up to 12 hours)
Adolescent/Adult/Geriatric (up to 10 hours)
Neurological Condition
Child (up to 8 hours)
Adolescent/Adult/Geriatric (up to 6 hours)
Testing Requested
96116
96118
96119
96120
Hours Requested______________
Hours Requested______________
Hours Requested______________
Hours Requested______________
Purpose_____________________________________________
Purpose_____________________________________________
Purpose_____________________________________________
Purpose_____________________________________________
__________________/__________________________
Psychologist Print/Signature
_________________
Date
_____________________
Phone
MercyCare Health Plan (MCHP) and Mercy Physician Association (MPA) Use Only
Date Received____________________
Received By__________________________________
Auth#_______________________________________
Auth Approved
Level: 1
2
3
#of Hours______ CPT Code____________ Denied
Reason_____________________________________________
____________________________________________________________________
________________________________________
Signature of Medical Director
Date
MPA only: Date denial discussed with PCP:_____________ PCP/MD response:___________________ Date written/electronic notification to member__________
Type: Approval
Denial
Closure
Date written /electronic notification to PCP/MD:________
MercyCare Health Plans●P.O. Box 2770●Janesville, WI 53547-2770
Phone 800-757-6825●Fax 608-758-7726
Revised TC052506