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Aetna Neuropsychological and Psychological Testing Coverage Information For Subscribers and Providers
Does Aetna insurance cover psychological testing?
Yes, Aetna insurance does cover neuropsychological (NPT) and psychological testing (PT) when specific criteria are met. These tests are considered medically necessary under certain circumstances.
How do I find out an Aetna provider that specializes in neuropsychological and psychological testing?
While the provided information doesn’t directly address how to find an Aetna provider, typically you can search on Aetna’s website or contact Aetna’s customer service for a list of providers that specialize in neuropsychological and psychological testing.
What is Aetna’s criteria for medical necessity?
Aetna considers neuropsychological and psychological testing medically necessary when certain criteria are met. For NPT, this includes:
- Testing to aid in assessing cognitive impairment due to medical or psychiatric conditions, considering:
- The number of hours for testing is reasonable.
- Testing techniques are validated for the diagnostic question.
- Techniques don’t repeat measurements of the same domain.
- Techniques are updated and valid for the patient’s age and population.
- Instruments chosen have reliability, validity, standardized administration, and clinically relevant data.
- Examples of NPT necessity include assessments after traumatic brain injuries, strokes, neurosurgery, or other medical diagnoses; assessments for developing rehabilitation strategies; differential diagnosis between psychogenic and neurogenic syndromes; and monitoring progression of cognitive impairment due to neurological disorders.
For PT, this includes:
- Testing to aid in the differential diagnosis of behavioral or psychiatric conditions when standard methods are insufficient.
- Testing to develop treatment recommendations when a member has tried various treatments without success.
- The testing adheres to the same technical and instrument guidelines as NPT.
Do I need a prior authorization?
The provided information does not explicitly state whether prior authorization is needed. However, given the detailed criteria for medical necessity, it’s recommended to consult with Aetna directly or check your specific policy details.
What happens if Aetna doesn’t cover my psychological testing?
If Aetna does not consider the neuropsychological or psychological testing to be medically necessary or if the testing is for educational, employment, disability qualification, or legal/court-related reasons, it won’t be covered. NPT and PT for educational purposes are typically provided by school systems under state and federal rules and are not covered by most of Aetna’s benefit plans. It’s essential to consult your benefit plan descriptions to determine coverage. If the testing relates to occupational or environmental medicine (e.g., due to solvent or heavy metal exposure), it might be covered by a worker’s compensation carrier instead of Aetna’s medical or mental health benefits.
In all cases where coverage is uncertain or denied, reaching out to Aetna directly or working with the testing provider to understand payment options is recommended.
What To Do When Seeing an Out-of-network provider?
Seeing an out-of-network provider involves different steps and considerations compared to seeing an in-network provider. One of the most common questions patients have in such scenarios is about getting a superbill. Here’s a detailed breakdown:
1. Understand Your Insurance Coverage:
Before scheduling an appointment, review your insurance plan’s details about out-of-network coverage. Some plans may offer partial reimbursement for out-of-network services, while others might not cover them at all.
2. Check the Costs:
Since out-of-network providers haven’t agreed to any set rates with your insurance company, their charges can be significantly higher. It’s a good practice to inquire about the costs in advance. Ask the provider about the expected cost for the visit and any treatments or tests they might recommend.
3. Ask About the Superbill:
A superbill is a detailed invoice from the healthcare provider that patients can submit to their insurance company for reimbursement. It’s more detailed than a standard receipt or invoice as it includes specific information insurance companies require, like diagnostic codes. If you’re considering seeking reimbursement from your insurance company for an out-of-network visit, ask the provider if they can give you a superbill after the appointment.
4. Be Prepared to Pay Upfront:
Out-of-network providers often require patients to pay for the full cost of the visit at the time of the service. This means you may need to pay upfront and then wait for reimbursement (if applicable) from your insurance company after submitting the superbill.
5. Submitting the Superbill for Reimbursement:
Once you have the superbill:
- Make a copy for your records.
- Submit the original to your insurance company. The exact submission process may vary by insurer, so it’s essential to check with them directly. Some may have online portals, while others may require mailing the superbill.
- After submission, track the claim’s status. Insurance companies may take several weeks to process out-of-network claims, and there may be additional information they need.