Get Ma Beacon Psychological Testing Request Form 2013-2026

Completing the MA Beacon Psychological Testing Request Form online is essential for obtaining pre-authorization for psychological testing. This guide will provide you with clear, step-by-step instructions to ensure that you fill out the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to download the form and open it in your preferred editor.
2. Begin by filling in the member's name, date of birth, health plan, and plan ID number in the designated fields. These details are crucial for identifying the member.
3. Provide the dates of any previous psychological or neuropsychological testing. If there are none, select the ‘None’ option.
4. Enter the name and discipline of the referring clinician, along with the provider agency name and their contact phone number.
5. Indicate the psychologist’s name who will be conducting the testing, include their phone number, Beacon Provider ID, and NPI number.
6. Describe the member’s current symptoms in detail and specify whether they are currently in outpatient treatment by selecting ‘Yes’ or ‘No’.
7. List the specific questions that the psychological testing aims to address, providing detailed descriptions.
8. Outline what steps have already been taken to address the clinical questions before requesting testing, detailing any relevant efforts.
9. Explain how the results of the psychological testing will facilitate treatment goals or provide new information. This should be specified in detail.
10. If applicable, provide details about any prior psychopharmacological consultations and information about any academic issues and special education needs.
11. Document any medical issues, including complications during pregnancy/birth, brain injuries, or head trauma.
12. List any current medications, both psychiatric and medical, as well as the history of substance use with specific details.
13. Enter the diagnosis under Axis I and Axis II as required.
14. Specify the psychological tests that are being requested along with the estimated time required for their administration and scoring.
15. Provide the requested CPT codes along with the estimated hours for each code.
16. Indicate the total units of hours requested and the specific dates for testing by filling in the date range.
17. Review all entries for accuracy and completeness before saving your changes, downloading the form, or printing it for submission.

Ensure your testing requests are handled efficiently by completing the MA Beacon Psychological Testing Request Form online today.