Insurance and payment

We are in-network with BCBS / Anthem PPO. That's real, and it can meaningfully lower your cost. It also comes with one honest truth: your out-of-pocket amount depends on your specific plan, not on us. Two people with BCBS can pay very different amounts for the same evaluation.

So before we meet, we ask you to do one small, powerful thing: call your insurance and ask a few questions. It takes about ten minutes and it removes the biggest unknown standing between you and getting started.

The exact script — copy, call, and ask:

I'd like to check my behavioral health / outpatient benefits for psychological and neuropsychological testing. My provider is in-network.

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Do I have coverage for psychological testing under CPT codes 96130 and 96131, and neuropsychological testing under 96132 and 96133, plus test administration codes 96136 and 96137?

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Is a diagnostic interview (90791) covered?

What is my deductible, and how much of it have I already met this year?

After my deductible, what is my coinsurance or copay for these services?

Do I need a referral or prior authorization for testing? If so, how do I get one?

Is there a limit on the number of testing hours or units per year?

Write down the answers — including the name of the representative and a reference number for the call. Bring them to your consultation, and we'll translate them into a real estimate together.

A few words that trip everyone up

Deductible

the amount you pay yourself before insurance starts sharing the cost. If your deductible is $2,000 and you haven't used any of it, you may be responsible for the first $2,000 of covered services.

Coinsurance

your share after the deductible is met, usually a percentage (like 20%).

Copay

a flat dollar amount for a visit, if your plan uses one.

Prior authorization / referral

permission some plans require before they'll cover testing. If yours needs it, we'll help you understand how to get it.

What medically necessary means — for ADHD and autism specifically

This is the phrase that confuses people most, and it's where coverage is won or lost. So here it is in full, plainly.

The basic idea. Insurance will only help pay for testing that is medically necessary — meaning it's done to answer a real clinical question that affects your health and daily functioning, not out of curiosity. To your insurer, "medically necessary" has a specific shape: there are documented difficulties interfering with your work, school, relationships, or daily life, and testing is the right step to understand what's driving them and what would help. If a request doesn't show that functional impact, insurance reads it as exploratory — and exploratory is the fastest way to a denial.

The thing no one tells you: insurance prefers the cheapest route that works. Insurers are allowed to ask, "Could this person get the same answer at a lower level of care, or somewhere less expensive?" If the answer is yes, they can deny. This is a real and common reason evaluations get turned down.

Here's why that argument usually fails for ADHD and autism — in your favor. Adult ADHD and, especially, adult autism are specialist evaluations. A primary care doctor can screen for symptoms, but the accepted next step is a referral to a psychologist for the formal, in-depth evaluation — and many prescribers will not treat ADHD or autism until a psychologist has confirmed the diagnosis. In other words, for these conditions there often is no cheaper equivalent that produces a valid diagnosis. That fact is not a technicality — it is the core of your medical-necessity case, and it's our job to state it clearly in your documentation.

  • Documented functional impairment — concrete ways symptoms interfere with work, school, relationships, or self-care.

  • A clear clinical question the testing will answer, not a general "I want to know."

  • For ADHD, often some indication that symptoms were present in childhood, not brand-new.

  • A referral or prior authorization if your plan requires one (this is why the benefits

    script above matters).

What insurance is looking for the things that get you approved:

  • The request looked exploratory — no functional impairment documented.

  • Prior authorization was required and not obtained before testing.

  • They decided it wasn't medically necessary or "could be done at a lower level of care."

  • The provider was out of network, or the hours/units allowed were exceeded.

Common reasons they deny so nothing surprises you:

The reassuring part. If you're seeking this evaluation, there is almost always a genuine clinical reason behind it — the exact kind that makes testing appropriate. You don't have to know how to say any of this. Documenting your clinical picture in the language your insurer needs to see is our job, and we do it as a matter of course. And if a claim is denied, that is not the end of the road: you have the right to appeal, mental-health parity law is on your side, and outside reviewers overturn these denials at meaningful rates. We'll tell you honestly where you stand.

Choosing to pay privately

You are always free to skip insurance and pay out of pocket, and some people choose this specifically for privacy. When you pay privately, we don't contact your insurer at all — nothing is submitted, there's no claim, and there's no Explanation of Benefits. For cash-pay evaluations, we'll also give you a Good Faith Estimate in writing before we begin, so there are no surprises.

One thing said plainly, so everything is clean and above-board: this has to be your decision. Because we're in-network with BCBS / Anthem, when you use your BCBS benefits we are required to bill the contracted rate — we cannot steer you away from your insurance in order to charge you more, and we wouldn't. But if privacy or simplicity leads you to choose private pay, that is entirely your call, and we'll honor it without a second thought. The cash prices listed above are exactly that.

Payment questions

  • For cash-pay evaluations, payment is due at intake before we begin. If you're using insurance, we'll walk you through how the deductible, coinsurance, and billing work for your situation so you know your part before anything starts.

  • Then you'll know that before you commit, and you can decide with real information — including whether the cash option makes more sense for you. No pressure, no surprises.

Worried about who can see your diagnosis if you use insurance? See Your Privacy.