☐ Confirm Clinical Information
Ensure the clinical note/order supports your request. Have it ready for quick reference.
☐ Clinical Assessment
☐ Presenting Problems & Symptoms: What’s driving the need for testing?
☐ Duration of Symptoms: The longer the duration, the stronger the case.
☐ Other Pertinent History: Any additional details that strengthen the request.
☐ Eg. BrainCheck Screen General Impression: Further Testing Recommended.
☐ ICD-10 Diagnosis
Ensure the diagnosis is accurate—medical necessity is essential for approval.
☐ Diagnostic Testing vs. Other Methods
Clarify why testing is needed over alternatives (interviews, consults, or medical records).
☐ Impact on Treatment Plan
Explain how the test results will affect the treatment plan.
☐ Testing Provider
Specify who is performing the testing (provider for code 96136 or technician for code 96138).
☐ CPT Code Requested
List the CPT codes 96136 or 96138, and 96132. Avoid 99483 to prevent denials.
☐ Total Units
Request 1 unit per CPT code (MUE = 1).
☐ Specify Names of Tests
Assess includes: Trails A (Attention), Trails B (Mental Flexibility), Stroop (Executive Function), Digit Symbol Substitution (Processing Speed), Immediate and Delayed Recognition (Memory).
☐ Medical Records
Ensure all relevant details are documented in the medical records to support the request.
By following this checklist, you’ll streamline the authorization process and reduce the risk of denials. If you need assistance, feel free to reach out for support.
See Below for a Full Sample of Prior Authorization Request:
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