Get Your Child Evaluated for Autism or ADHD Without Losing a Year

  1. Call your insurer and request the medical-necessity criteria and covered CPT codes for autism and ADHD evaluations
    30 min

    This step produces a written document or email from your insurer that states the medical-necessity criteria for autism and ADHD diagnostic evaluations and lists the specific CPT codes they cover. Without these two documents, you cannot verify whether a provider’s planned billing will be paid, and you cannot check whether your child meets the insurer’s criteria before you spend weeks in a prior-authorization process.

    How to get the documents

    1. Call the customer-service number on the back of your insurance card. Ask for the behavioral-health or mental-health department.
    2. Provide your policy number and your child’s name and date of birth.
    3. Say: “I need a written copy of the medical-necessity criteria for a diagnostic evaluation for autism spectrum disorder and for ADHD.”
    4. Say: “Please give me a list of the covered CPT codes for these evaluations.” The main codes to ask about are 90791 (diagnostic interview), 96130–96133 (psychological and neuropsychological testing), and 96136–96139 (test administration and scoring by a psychologist or technician). Confirm each is covered in-network.
    5. Ask for the representative’s name, a reference or case number, and the expected delivery date of the written confirmation.
    6. Request the documents by email and also through your member portal.
    7. Record the reference number and the representative’s name in your notes.