You are on page 1of 15

3.704.

3 List of Psychological Tests


Material was prepared for use as an aid in handling requests for psychological testing. The minutes allocated for each test include administration, scoring and write up. Determination of the medical necessity of psychological tests always requires consideration of the clinical facts of the specific case to assure that tests given are a cost-effective means of determining the appropriate treatment for the individual patient and are related to the diagnosis and treatment of covered mental health conditions. INSTRUMENT 16 Personality Factor Questionnaire (16-PF) ABEL Screen Achenbach System of Empirically Based Assessment Preschool Module Caregiver-Teacher Report Form Child Behavior Checklist (CBCL) Teacher Report Form Youth Self-Report (YSR) ACTeERS-ADD-H Comprehensive, Teachers Rating Scale Adaptive Behavior Assessment System (ABAS II) Adaptive Behavior Scale (ABS) ADHD Rating Scale Adolescent Anger Rating Scale Adolescent Apperception Cards Adult Behavior Checklist (ABCL) Adolescent Psychopathology Scale Alzheimers Quick Test (AQT) Amen System Checklist Animal Naming Aphasia Screening Test (Reitan Indiana) Aspergers Syndrome Diagnostic Scales (ASDS) Attention Deficit Disorder Eval. Scales (ADDES) Attention-Deficit/Hyperactivity Disorder Test (ADHDT) Attention-Deficit Scales for Adults (ADSA) Auditory Consonant Trigram Test (ACT) Auditory Continuous Performance Test Australian Scale for Aspergers Syndrome Behav Rating Scale Behav Rating Scale Behav Rating Scale Behav Rating Scale Behav Rating Scale Behav Rating Scale Behav Rating Scale Developmental Behav Rating Scale Behav Rating Scale Projective Personality Behav Rating Scale Personality Neuro Behav Rating Scale Neuro Neuro Rating scale Behav Rating Scale Behav Rating Scale Behav Rating Scale Neuro, educational Attention; ADHD Rating scale 1.5-5 1.5-5 1.5-5 6-18 11-18 5 13 0-89 3-18 4 18 11-19 12 19 18-89 Child-adult Adult Adult Child-adult 5+ 5-18 5 18 3-23 17+ 16-69 6 11 Primary Personality Sexual Interest TYPE AGE 16+ Adol + MINUT ES 30 120 60 10 10 15 20 20 15 30 30 15 15 60 30 60 10 15 10 30 20 15 10 15 15 30 15 On-line, self scoring Admin. Time 20 min. + 10 min. for scoring, interpretation, write up. COMMENTS 35-60 min per Tests in Print for admin time only Primarily forensic in nature: may not be covered

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 1 of 15

3.704.3 List of Psychological Tests


Material was prepared for use as an aid in handling requests for psychological testing. The minutes allocated for each test include administration, scoring and write up. Determination of the medical necessity of psychological tests always requires consideration of the clinical facts of the specific case to assure that tests given are a cost-effective means of determining the appropriate treatment for the individual patient and are related to the diagnosis and treatment of covered mental health conditions. INSTRUMENT TYPE AGE school Autism Diagnostic Interview (ADI-R) Autism Diagnostic Observation Scale (ADOS) Basic Personality Inventory (BPI) Battell Developmental Inventory Battery for Health Improvement (BHI) Bayley Scales of Infant Development Beck Anxiety Inventory Beck Depression Inventory Beck Depression Inventory-II (BDI-II) Beck Hopelessness Scale (BHS) Beck Scale for Suicidal Ideation Beck Youth Inventory Beery VMI (Test of Visual-Motor Integration) Behavior Assessment System for Children (BASC) Behavior Rating Inventory of Executive Functioning (BRIEF) Bender Visual Motor Gestalt Test Benton Facial Recognition Test Benton Judgment of Line Orientation Test Benton Multilingual Aphasia Exam (BMAE) Benton MAE Sentence Repetition Benton MAE Token Test Benton MAE: Visual Naming Test Benton Right-Left Orientation Test Benton Serial Digit Learning Test Benton Visual Form Discrimination Test Benton Visual Retention Test Booklet Categories Test Boston Diagnostic Aphasia Examination-3 Boston Naming Test Autism diagnosis Rating scale Personality Test Developmental Assessment Personality Test Development Personality Test Personality Test Personality Test Personality Test Pers Rating Scale Symptom Rating Scale Neuro/LD: Visual Behav Rating Scale Neuro Neuro Neuro Neuro Neuro Neuro Neuro Neuro Neuro Neuro Neuro Neuro Neuro Neuro Neuro Mental age >2 Toddler-Adult 12+ 0-7 18-65 1-42 months 17-80 17-80 13 80 17 80 17 80 7-14 3+ 4 - 18 Child/adolesce nt 4+ 6-74 7+ 6-69 6-69 6-69 6-69 16-64 16-64 Adult 8+ 15+ Adults Adults 60 60 35 30 25-40 60 15 15 15 15 15 15 30 30 45 30 30 20 90 15 15 15 10 15 15 30 45 60 30 Versions for preschool and child/adolescent Neuro; not for personality assessment Relationships between psychopathology and pain 90-150, should substitute for other measures MINUT ES COMMENTS

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 2 of 15

3.704.3 List of Psychological Tests


Material was prepared for use as an aid in handling requests for psychological testing. The minutes allocated for each test include administration, scoring and write up. Determination of the medical necessity of psychological tests always requires consideration of the clinical facts of the specific case to assure that tests given are a cost-effective means of determining the appropriate treatment for the individual patient and are related to the diagnosis and treatment of covered mental health conditions. INSTRUMENT BRIEF (Behavior Rating Inventory of Executive Functioning) Brief Neuropsychological Cognitive Exam Brief Symptom Inventory Brief Test of Attention (BTA) Brief Visuospatial Memory Test-Revised (BVMT-R) Brown Attention-Deficit Disorder Scales Burks Behavior Rating Scale Burt Word Reading Buschke Selective Reminding Test California Psychological Inventory (CPI) California Verbal Learning Test (CVLT) California Verbal Learning Test for Children (CVLT) Carroll Depression Scale Category Test Child Bipolar Questionnaire (CBQ) Childrens Apperception Test (CAT) Childrens Attention & Adjustment Survey (CAAS) Childrens Atypical Development Scale Childrens Auditory Verbal Learning Test-2 (CAVLT) Childrens Category Test (CCT) Childrens Depression Inventory (CDI) Childrens Depression Rating Scale, Revised Childrens Personality Questionnaire (CPQ) Childrens Self Report Projective Inventory Child Development Inventory-4 Child Symptom Inventory (CSI) Childhood Autism Rating Scales (CARS)-2 Childhood Trauma Questionnaire TYPE Neuro/Educational Neuro Behav Rating Scale Attention Measure Neuro Behav Rating Scale Behav Rating Scale Educational Neuro Objective Personality Test Neuro: Memory/Learning Neuro: Memory/Learning Rating Scale Neuro Behav Rating Scale Projective Personality Test Behav Rating Scale Rating Scale Neuro-Memory/Learning Neuro Personality Personality Pers Inventory Projective Personality Test Development/Personality Rating Scale Rating Scales Personality Scale AGE Child/adolesce nt 13+ 13+ 17-82 18-79 12+ Preschool Child 5-91 13+ 17+ 5 16.1 18+ 15+ 5-18 3-10 5 13 Child 6.5-18 5 16 7-17 6 12 8-12 5-12 15 mos.-6 6-12 2+ 12+ MINUT ES 45 30 5 15 60 15 15 5 30 30 45 45 15 45 15 60 15 15 45 15 15 15 30 120 60 15 15 15 Juvenile onset bipolar rating scale- parent administered Norms only on normal population Short form of SLR-90-R. COMMENTS Versions for preschool and child/adolescent

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 3 of 15

3.704.3 List of Psychological Tests


Material was prepared for use as an aid in handling requests for psychological testing. The minutes allocated for each test include administration, scoring and write up. Determination of the medical necessity of psychological tests always requires consideration of the clinical facts of the specific case to assure that tests given are a cost-effective means of determining the appropriate treatment for the individual patient and are related to the diagnosis and treatment of covered mental health conditions. INSTRUMENT Clinical Evaluation of Language Fundamentals (CELF)-4 Childrens Manifest Anxiety Scale Revised Childrens Memory Scale (CMS) Childrens Personality Questionnaire Childrens State-Trait Anxiety Inventory Chronic Pain Battery Clock Drawing Cognistat Cognitive Abilities Scale II (CAS) Cognitive Assessment System (CAS) Cognitive Coping Strategies Inventory-R Color Trails Test Comprehensive Assessment of Spoken Language (CASL) Comprehensive Behavior Rating Scale for Children (CBRSC) Comprehensive Test of Nonverbal Intelligence (CTONI) Comprehensive Test of Phonological Processing (CTOPP) Comprehensive Trail Making Test (CTMT) Computer Category Test Computerized Assessment of Response Bias (CARB) Conners Adult ADHD Rating Scale (CAARS) Conners Continuous Performance Test II (CCPT) Conners Continuous Performance Test, Kiddie Version (KCPT) Conners Rating Scale-Teacher or Parent Conners Rating Scales-Revised Contextual Memory Test (CMT) Controlled Oral Word Association Test (COWAT or COWA) Coping Responses Inventory (CRI) D2 Test of Attention Neuro Personality Neuro Personality Beh Rating scale Pain adaptation Neuro Neuro Neuro/Educational Neuro/educational Rating Scale Neuro Neuro; Educational Behav Rating Scale Nonverbal test of Intelligence Neuro/Educational Neuro Neuro Neuro; Forensic Behav Rating Scale Neuro Neuro, Forensic Behav Rating Scale Behav Rating Scale Neuro; educational Neuro; educational Personality Attention TYPE AGE 5-21 6 19 5 16 8-12 8 14 Adult Not stated 18+ 5-18 5-18 Adult Adult-Older Ad. 3-21 6 14 6-19 5-24 8-74 15-80 Adult 18+ 4+ 4-5 3- 17 3 17 Adult 16+ 12-90 Child-Adult MINUT ES 30 15 60 45 15 15 15 30 60 60 15 10 60 15 60 45 15 45 15 15 60 15 15 15 30 15 20 10 Effort, malingering 45 for children 3-5 60 for basic; 75 for standard COMMENTS

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 4 of 15

3.704.3 List of Psychological Tests


Material was prepared for use as an aid in handling requests for psychological testing. The minutes allocated for each test include administration, scoring and write up. Determination of the medical necessity of psychological tests always requires consideration of the clinical facts of the specific case to assure that tests given are a cost-effective means of determining the appropriate treatment for the individual patient and are related to the diagnosis and treatment of covered mental health conditions. INSTRUMENT Delis-Kaplan Executive Functional Scale (D-KEFS) Dementia Rating Scales (Mattis) Depression and Anxiety in Youth Scale (DAYS) Detailed Assessment of Posttraumatic Stress (DAPS) Detroit Test of Learning Aptitude (DTLA)-4 Developmental Indicators for the Assessment of Learning (DIAL)-3 Developmental Profile II Developmental Test of Visual Perception (DTVP)-2 Devereau Scales of Mental Disorders Diagnostic Achievement Battery 2 (DAB2) Diagnostic Assessment of Reading (DAR) Differential Ability Sale (DAS) Digit Vigilance Test Dot Counting Test (DCT) Draw-a-Person (DAP) Dyadic Adjustment Scale Dyslexia Screening Instrument Early Childhood Attention Deficit Disorders Evaluation Scale (ECADDES) Eating Inventory Eating Disorder Inventory 2 (EDI-2) Endler Multidimensional Anxiety Scales Estimate of Risk of Adolescent Sexual Offense Recidivism (ERASOR) Examining for Aphasia Executive Control Battery (ECB) Expressive One Work Vocabulary Test Revised Expressive Oral-Word Picture Vocabulary Test (EOPVT) Family Apperception Test Neuro: Exec Neuro: Screen Objective Personality Personality Intelligence Educational; Neuro Neuro; Educational Development; Neuro Personality Academic achievement Neuro; Educational Educational; Neuro Neuro Neuro; Forensic Projective Personality Personality Educational Beh Rating scale Personality Personality Pers Rating Scale Sex offender assessment Neuro Neuro Neuro Neuro Projective Personality Test TYPE AGE 8-89 65-81 6-19 18-91 6-17 3-7 0-9.5 4-9 5-18 6-14 5-Adult 6-18 20-80 17+ Child-Adult Adult 6-21 2-7 F; 2-6.5 M 17+ 12+ 13+ 12-18 13 adult Not Specified 2-12 2-80 6 15 MINUT ES 120 60 45 60 120 40 40 45 30 60 30 60 20 15 15 15 20 20 15 15 15 15 75 60 20 15 30 Forensic; may not be covered Effort, malingering Primarily educational; may not be covered COMMENTS

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 5 of 15

3.704.3 List of Psychological Tests


Material was prepared for use as an aid in handling requests for psychological testing. The minutes allocated for each test include administration, scoring and write up. Determination of the medical necessity of psychological tests always requires consideration of the clinical facts of the specific case to assure that tests given are a cost-effective means of determining the appropriate treatment for the individual patient and are related to the diagnosis and treatment of covered mental health conditions. INSTRUMENT Family Kinetic Drawing Fear-Avoidance Beliefs Questionnaire (FABQ) Feelings, Attitudes and Behaviors Scale for Children Finger Tapping Test (Electric or Manual) Folstein Mini Mental Status Frontal Systems Behavior Scale Fuld Object Memory Evaluation Fundamental Interpersonal Relations Orientation-Behavior (FIRO-B) General Ability Measure for Adults (GAMA) Gilliam Autism Rating Scale (GARS-2) Gilliam Aspergers Disorder Scale (GADS) Gordon Diagnostic System Gray Oral Reading Test (GORT-R or GORT-3) Gray Silent Reading Test Green Word Memory Test Grip Strength Grooved Pegboard Guilford-Zimmerman Temperament Survey Halstead Reitan Neuro Battery Hamilton Depression Inventory (HDI) Hamilton Rating Scale for Depression-Revised (Clinician Form) Hamilton Rating Scale for Depression-Revised (Self-Report) Hand Test Hare Psychopathy check list-R (PCL-R) High School Personality Inventory Holtzman Inkblot Test/Technique Home Situations Questionnaire (HSQ, HSQ-R) Hooper Visual Organization Test (VOT) Hopkins Verbal Learning Test-R TYPE Projective Personality Test Back Pain Assessment Behav Rating Scale Neuro Neuro Neuro Neuro: Memory Personality Intelligence Rating scale Rating scale Attention Educational Educational; Neuro Neuro Neuro Neuro Personality Neuro Battery Symptom rating scale Personality Pers Rating Scale Projective Personality Personality Personality Projective Personality Beh Rating Scale Neurosych Neuro AGE Child+ Not Specified <12 Child+ Adult 18-95 70-90 Adult 18-80 3-22 3-22 4+ Child+ 7-25 Not listed 6+ 5-89 16+ Child+ 18+ 18+ 18+ Adult 18+ 13+ Child+ 4-18 5+ 16-92 MINUT ES 30 10 10 5 15 25 15 15 45 15 15 60 45 45 30 5 10 60 N/A 15 0 15 45 150 30 120 15 30 20 Part of MSE only Assessment of normal personality rather than clinical assessment See times for individual tests from this battery (6) Geriatric Should be part of 90801 intake assessment rather than testing COMMENTS

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 6 of 15

3.704.3 List of Psychological Tests


Material was prepared for use as an aid in handling requests for psychological testing. The minutes allocated for each test include administration, scoring and write up. Determination of the medical necessity of psychological tests always requires consideration of the clinical facts of the specific case to assure that tests given are a cost-effective means of determining the appropriate treatment for the individual patient and are related to the diagnosis and treatment of covered mental health conditions. INSTRUMENT House Tree Person (H-T-P) Human Figure Drawings Impact of Weight on Quality of Life Questionnaire (IWQOL) Incomplete Sentences Blank Independent Living Scales (ILS) Integrated Visual and Auditory Continuous Performance Test (IVACPT) Jesness Inventory Jesness Inventory Revised (JI-R) TYPE Projective Personality Projective Personality Personality Proj Neuro; Forensic Attention Antisocial personality Antisocial personality AGE Child+ Child+ Adult Child+ 65+ 6-96 8-adult 8-adult MINUT ES 30 30 15 15 45 60 45 60 Personality for delinquent and conduct d/o, personality for delinquent and conduct d/o 8--adult Admin time- 20-30 min., however output is multidimensional and may take considerable time to interpret and integrate into other assessment data. http://www.mhs.com/product.aspx?gr=saf&prod=ji-r&id=resources Competency in performing ADLs Child version for ages 11-19 COMMENTS

Jordon Left-Right Reversal Test-R J-Soap Juvenile Sex Offender Assessment Protocol Judgment of Line Orientation Kaufman Brief Intelligence Test (K-BIT) Kaufman Adolescent and Adult Intelligence Test Kaufman Assessment Battery for Children (KABC) Kaufman Functional Academic Skills Test (K-FAST) Kaufman Short Neuropsychological Assess Procedure (K-SNAP) Kaufman Test of Education Achievement (K-TEA) Key-Math Diagnostic Arithmetic Test Revised Kinetic Family Drawings (KFD) Lateral Dominance Exam Learning Disabilities Diagnostic Inventory (LDDI) Leiter International Performance Scale Revised (Leiter-R) Louisville Behavioral Checklist Luria-Nebraska Neuropsych Battery Luria-Nebraska Neuropsych Screen Version Luria-Nebraska Neuropsych Battery for Children Luria-Nebraska Neuropsych for Children Screen Version

Neuro; Educational Sex offender assessment Neuro Intelligence Intelligence Intelligence& Academic Skills Developmental Neuro screen Educational Educational Projective Personality Neuro Educational Intelligence Beh Rating Scale Neuro Neuro Neuro Neuro

5-12 9-20 Adult 4-90 11-85 2.5-12.5 15-85 11 85 6-18 5-14 Child+ Child-Adult 8-18 2-20 4-17 13+ 13+ 8-12 8-12

20 60 30 30 90 90 30 30 60 80 30 25 30 60 15 150 30 150 30 Adaptive behavior inventory. 15-25 for admin. Forensic; may not be covered

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 7 of 15

3.704.3 List of Psychological Tests


Material was prepared for use as an aid in handling requests for psychological testing. The minutes allocated for each test include administration, scoring and write up. Determination of the medical necessity of psychological tests always requires consideration of the clinical facts of the specific case to assure that tests given are a cost-effective means of determining the appropriate treatment for the individual patient and are related to the diagnosis and treatment of covered mental health conditions. INSTRUMENT Make a Picture Story Marital Satisfaction Inventory-Revised (MSI-R) Maryland Addictions Questionnaire (MAQ) McCarthy Scales of Childrens Abilities McGill Pain Inventory Memory Assessment Scales Millon Adolescent Personality Inventory (MAPI) Millon Behavioral Medicine Diagnostic (MBMD) Millon Clinical Multiaxial Inventory-III (MCMI) MicroCog Assessment of Cognitive Functioning Millon Adolescent Clinical Inventory (MACI) Millon Adolescent Personality Inventory (MAPI) Millon Behavioral Health Inventory (MBH/MBHI) Millon Pre-Adolescent Clinical Inventory (M-PACI) Minnesota Multiphasic Pers. Inventory-2 (MMPI-2) Minnesota Multiphasic Pers. Inventory-Adolesc. (MMPI-A) Minnesota Test for Differential Diagnosis of Aphasia Mooney Problem Check Lists Motor-Free Visual Perception Test Mullen Scales of Early Learning Multidimensional Anxiety Scale for Children (MASC) Multidimensional Health Profile Multilingual Aphasia Examination (MAE)-3 Multiphasic Sex Inventory Multiscore Depression Inventory for Children Multiscore Depression Inventory for Adolescents and Adults Nelson-Denny Reading Test (Forms G and H) NEO Personality-R (NEO PI-R) NEPSY (Developmental Neuropsychological Assessment) TYPE Projective Personality Marital/Relationship Chemical Dep Intelligence Personality, pain coping Neuro Personality Personality Personality Neuro Personality Pers Inventory Medical Coping Style Pers Inventory Personality Personality Neuro Personality Neuro; Educational Neuro; Educational Pers Inventory Pers Inventory Neuro Sex offender assessment Personality Personality Educational; Neuro Personality Neuro AGE Adolescent 18 90 16+ 2.6-8.6 18+ 18-90 13-18 18-85 18+ 18 89 13-19 13-19 18+ 9-12 18+ 13-18 Adults Jr. High-Adult 4-8 Birth-68 months 8-19 18-90 6-69 Adult 8 17 17+ 9-Adult 17+ 3-12 MINUT ES 60 15 15 90 15 60 60 30 60 60 60 60 60 30 60 60 90 35 25 15 (1yr) 30 15 60 60 15 15 30 30 120 60 for pre-school; 120 for school age children Versions for adolescent and adult males 25-35 (3yrs), 40-60 (5yrs) Assumes 6th grade reading level Has bariatric norms COMMENTS

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 8 of 15

3.704.3 List of Psychological Tests


Material was prepared for use as an aid in handling requests for psychological testing. The minutes allocated for each test include administration, scoring and write up. Determination of the medical necessity of psychological tests always requires consideration of the clinical facts of the specific case to assure that tests given are a cost-effective means of determining the appropriate treatment for the individual patient and are related to the diagnosis and treatment of covered mental health conditions. INSTRUMENT Neuropsychological Assessment Battery (NAB) Neuropsychological Impairment Scale Neuropsych Questionnaire (NPQ) Neuropsych Questionnaire Short Form (NPQ-SF) NICHQ Vanderbilt Assessment Scale Omni Personality Inventory Omni IV Personality Disorder Inventory Oral and Written Language Skills (OWLS) Paced Auditory Serial Addition Task (PASAT: C) Pain Apperception Test Pain Patient Profile (P3) Parent-Child relationship Inventory (PCRI) Parenting Stress Index (PSI) Paulhaus Deception Scales Peabody Developmental Motor Scales and Activity Cards Peabody Individual Achievement Test Revised (PIAT-R) Peabody Picture Vocabulary Test Revised (PPVT-R) Pediatric Attention Disorders Diagnostic Screener (PADDS) Personal Experience Inventory for Adolescents (PEI) Personal Experience Inventory for Adults (PEI-A) Personality Assessment Inventory (PAI) Personality Inventory for Children-R Personality Inventory for Youth (PIY) Personality Research Form (PRF) PHASE Philadelphia Head Injury Questionnaire Piers-Harris Children's Self Anapt Scale Porteus Mazes Posttraumatic Stress Diagnostic Scale (PDS) Neuro Neuro screen Neuro / Beh Rating Scale Neuro / Beh Rating Scale Beh Rating Scale Pers Inventory Pers Inventory Educational; Neuro Neuro: Attention Pain disorders Pain disorders Prenatal Style Parental Style Personality Developmental Educational Intelligence; Educational Beh Rating Scale Chemical Dep Chemical Dep Personality Personality Pers Inventory Personality Sex offender assessment Neuro Personality Intelligence; Neuro Personality TYPE AGE 18-97 18 88 Child-Adult Child-Adult 6-12 18-74 18-74 3-21 16+ Adult 17-76 3 12 3 12 16+ 07 5 18 2.5-Adult 6-12 12 18 19+ 18+ 3-16 9-19 11+ Not Specified Adult 7-18 3+ 18-65 MINUT ES 240 15 45 10 15 60 60 40 45 15 15 15 15 15 90 75 30 60 15 30 60 30 30 60 30 15 15 30 15 Forensic; may not be covered, sexual attitudes Includes ratings scales and executive function measures Measures response distortion NPQ is a computer administered & scored questionnaire; developed and used in NC NPQ Follow-up version COMMENTS 6 different modules @ 40 minutes each

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 9 of 15

3.704.3 List of Psychological Tests


Material was prepared for use as an aid in handling requests for psychological testing. The minutes allocated for each test include administration, scoring and write up. Determination of the medical necessity of psychological tests always requires consideration of the clinical facts of the specific case to assure that tests given are a cost-effective means of determining the appropriate treatment for the individual patient and are related to the diagnosis and treatment of covered mental health conditions. INSTRUMENT Preschool Language Scale, 4th Edition (PLS-4) Problem Behavior Inventory Problem Experiences Checklist Process Assessment of the Learner (PAL)-II Progressive Figures Test Projective Drawings Psychological Screening Inventory Purdue Pegboard QB Test Quality of Life Inventory (QOLI) Quick Neurological Screening Test-2 (QNST-2) Quotient Test of Attention Ravens Progressive Matrices (all versions) Receptive One Word Picture Vocabulary Test (ROWPVT) Repeatable Battery for Assessment of Neuropsychological Status (RBANS) Resiliency Scales for Children and Adolescents Revised Behavior Problem Checklist (RBPC) Revised Childrens Manifest Anxiety Scale (RCMAS)-2 Revised Token Test Rey Auditory Verbal Learning Test Rey 15-Item Testmove to alphabetic order Reynolds Adolescent Depression Scale-2 Reynolds Adolescent Adjustment Screening Inventory Reynolds Child Depression Scale Reynolds Intellectual Assessment Scales (RIAS) Reynolds Intellectual Screening Test (RIST) Rey-Osterrieth Complex figure Test (RCFT) Rivermead Behavioral Memory Test TYPE Educational; Neuro Pers Rating Scale Personality Educational Neuro Personality Personality Neuro Attention/ADHD Personality Neuro Attention IQ/Neuro; Problem Solving Neuro Neuro Personality Beh Rating Scale Personality Neuro ; Educational Neuro Neuro, malingering Personality Personality Personality Intelligence Intelligence Neuro Neuro 16-96 AGE 0-6 13+ 13 19 Grades K-6 5-8 Child-Adult AdolescentAdult Child + 6-55 17+ 12 to adults Child-Adult 6.5+ 2-95 20-89 9-18 5 18 6-19 20-80 7-89 Adult 11-20 12-19 7-12 3-94 3-94 MINUT ES 60 15 15 30-60 15 30 15 15 60 5 30 60 45 30 30 30 15 15 30 15 15 15 15 15 45 15 30 45 May be primarily forensic Not a clinical test but may be useful in some assessments (e.g. pain) W/all subtests, 1-6 min per subtest. COMMENTS

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 10 of 15

3.704.3 List of Psychological Tests


Material was prepared for use as an aid in handling requests for psychological testing. The minutes allocated for each test include administration, scoring and write up. Determination of the medical necessity of psychological tests always requires consideration of the clinical facts of the specific case to assure that tests given are a cost-effective means of determining the appropriate treatment for the individual patient and are related to the diagnosis and treatment of covered mental health conditions. INSTRUMENT Rivermead Perceptual Assessment Battery-III Roberts Apperception Test for Children (RATC) Rorschach Rosenzweig Picture Frustration Study Rotter Incomplete Sentence Test Risk-Sophistication-Treatment Inventory (RSTI) Ruff 2 & 7 Selective Attention Test Scales of Independent Behavior (Woodcock Johnson) (SIB)-R SCAN-3C: Test for Auditory Processing Disorders in Children Scholastic Abilities Test for Adults (SATA) School Behavior Checklist School Motivation and Learning Strategies Inventory (SMLSI) School Situations Questionnaire (SSQ, SSQ-R)/Survey Screener and Opioid Assessment for Patients with Pain- Revised (SOAPP-R) Seashore Rhythm Test Sensory Profile Severe Impairment Battery (SIB) Sexual Adjustment Inventory-Juvenile Sexual Attitude Questionnaire Shipley Institute of Living Scale Short Category Test, Booklet Format Short Sensory Profile Sixteen Personality Factor Questionnaire (16PF) Slosson Full-Range Intelligence Test (S-FRIT) Slosson Intelligence Test Revised Social Communication Questionnaire (SCQ) Social Phobia and Anxiety Inventory Social Responsiveness Scale (SRS) Speech Sounds Perception Test Neuro Projective Personality Projective Personality Personality Projective Personality Sex offender assessment Neuro Developmental Educational; Neuro Educational; Neuro Beh Rating Scale Beh Rating Scale Behavioral Rating Scale Pain assessment Neuro: Perceptual Neuro; Developmental Neuro Sex offender assessment Sex offender assessment Intelligence Neuro: Problem Solving Neuro; Developmental Pers Inventory Intelligence Intelligence Rating Scale Beh Rating Scale Beh Rating Scale Neuro TYPE AGE 16-96 6-15 Child+ 14-85 Child+ 9-18 16-70 0-80 5-12 16-70 4 13 8-18 6-12 Adult 15+ 3-10 Adult 14-18 Teen + 14+ 15+ 3-10 16+ 5 21 4+ 4+ 14+ 4-18 9-Adult MINUT ES 60 60 120 30 60 60 30 60 60 60-120 15 15 15 15 20 25 30 90 15 30 35 15 30 45 30 15 15 30 30 Autism spectrum symptom severity. Admin. time 15-20 min. produces several indictors and subscales. For Autism Spectrum; requires mental age. 2 Forensic; may not be covered, norms 14-18 Forensic; may not be covered, 40 items Forensic; may not be covered Includes scoring COMMENTS

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 11 of 15

3.704.3 List of Psychological Tests


Material was prepared for use as an aid in handling requests for psychological testing. The minutes allocated for each test include administration, scoring and write up. Determination of the medical necessity of psychological tests always requires consideration of the clinical facts of the specific case to assure that tests given are a cost-effective means of determining the appropriate treatment for the individual patient and are related to the diagnosis and treatment of covered mental health conditions. INSTRUMENT Structured Clinical Interview (SCID II Patient Questionnaire) Standardized Reading Inventory- 2 Edition (SRI-2) requiresStanford Binet Intelligence Scale State-Trait Anger Expression Inventory State-Trait Anxiety Inventory Stroop Color Naming Substance Abuse Subtle Screening Inventory (SASSI) Suicidal Ideation Questionnaire Suicide Probability Scale Survey of Teenage Readiness and Neurodevelopment Status (STRANDS) Symbol-Digit Modalities test Symptom Assessment 45 (SA-45) Symptom Checklist 90 Revised (SCL-90-R) Tactual Performance Task (TPT) Target Test Tasks of Emotional Development (TED) Taylor-Johnson Temperament Analysis Tell-Me-A-Story (TEMAS) Test of Auditory Analysis Skills (TAAS) Test of Auditory Comprehension of Language-3 Test of Auditory-Perceptual Skills (TAPS)-R Test of Early Math Ability (TEMA) Test of Early Reading Ability (TERA)-3 Test of Emotional Development (TED) Test of Everyday Attention (TEA) (TEA-CH for children) Test of Language Competence-Expanded (TLC-E) Test of Language Development Primary (TOLD P:3) Test of Language Development Intermediary (TOLD P:3)
nd

TYPE Beh Rating Scale Educational; Neuro Intelligence Beh Rating Scale Beh Rating Scale Neuro: Attention Chemical Dep Symptom rating scale Personality Neuro; Developmental Neuro: Attention Sex offender assessment Symptom Checklist Neuro Neuro Projective Personality Personality/Marital Projective Personality Educational Educational; Neuro Educational Educational Educational Projective Personality Attention Educational Neuro/language/educational Neuro/language/educational

AGE 18+ 6-14 2-adult 12 67 15+ 7+ 12+ 12 18 13+ 13-19 6+ 13+ 13+ 5+ 5+ Approx 613+ 5 18 5-8 3-9 4-18 3-8 3-8.5 6+ 18 80 5-18 4-8 8-12

MINUT ES 30 60 120 15 15 20 15 15 15 60 20 15 15 35 35 60 30 60 10 30 30 30 30 20 60 60+ 60 60 Minorities and non-minorities Forensic; may not be covered

COMMENTS Structured interview for DSM-IV-TR-Axis II

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 12 of 15

3.704.3 List of Psychological Tests


Material was prepared for use as an aid in handling requests for psychological testing. The minutes allocated for each test include administration, scoring and write up. Determination of the medical necessity of psychological tests always requires consideration of the clinical facts of the specific case to assure that tests given are a cost-effective means of determining the appropriate treatment for the individual patient and are related to the diagnosis and treatment of covered mental health conditions. INSTRUMENT Test of Memory Malingering (TOMM) Test of Memory and Learning (TOMAL) Test of Nonverbal Intelligence-3 (TONI-3) Test of Pragmatic Language (TOPL) Test of Problem Solving (TOPS) Test of Variables of Attention (TOVA) Test of Visual-Motor Integration (see Beery VMI) Test of Visual Motor Skills, Upper Level Test of Visual-Motor Skills, Revised Test of Visual-Perceptual Skills Revised (non-motor) (TVPS-3) Test of Visual-Perceptual Skills Revised (non-motor) Upper Level (TVPS-3) Test of Word Reading Efficiency (TOWRE) Test of Written Language (TOWL)-4 Thematic Apperception Test (TAT) Token Test (Revised Token Test, Token Test for children) Tower of London Trail Making Test Trauma Symptom Checklist for Children (TSC) Trauma Symptom Inventory (TSI) Validity Indicator Profile (VIP) Vineland Adaptive Behavior Scales (VABS) Vineland Social-Emotional Early Childhood Scales VisualMotor Integration (VMI) Visual-Aural Digit Span Test Wechsler Adult Intelligence Scale III (WAIS-III) Wechsler Adult Intelligence Scale IV (WAIS-IV) Wechsler Adult Intelligence Scale Revised as a Neurological Instrument (WAIS-R NI) TYPE Malingering/Effort Neuro-Mem-LD Intelligence Educational Educational; Neuro Attention Neuro; Developmental Neuro: Educational Neuro: Educational Neuro: Educational Neuro: Educational Educational Educational Projective Personality Neuro-Language Neuro Neuro; Attention Personality Personality Malingering Developmental Emotional Developmental Neuro: Visual Neuro/LD; Memory IQ-Multitask IQ-Multitask IQ/Neuro AGE 16+ 5-19.11 6 89 6-18 6-11 4-80 3+ 12 40 3 13 4 13 12 18 6-25 7-17 Adoles+ 3+ Child-Adult 6-97 8 16 18+ 18-69 0-18.11 5 11 3+ 12+ 16-74 16-74 16-74 MINUT ES 15 60 30 45 25 60 30 20 20 30 20 15 90 60 30 30 15 15 30 60 75 30 20 20 135 135 180 Young children version ages 3-12 COMMENTS

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 13 of 15

3.704.3 List of Psychological Tests


Material was prepared for use as an aid in handling requests for psychological testing. The minutes allocated for each test include administration, scoring and write up. Determination of the medical necessity of psychological tests always requires consideration of the clinical facts of the specific case to assure that tests given are a cost-effective means of determining the appropriate treatment for the individual patient and are related to the diagnosis and treatment of covered mental health conditions. INSTRUMENT Wechsler Abbreviated Scale of Intelligence (WASI) Wechsler Individual Achievement Test (WIAT) Wechsler Individual Achievement Test for Children (WIAT) Wechsler Intell Scale for Children (WISC-IV) Wechsler Memory Scale 3rd Ed. (WMS-III) Wechsler Preschool & Primary Scale of Intell. Rev (WPPSI-R) Wechsler Test of Adult Reading (WTAR) Wender Utah Rating Scale Wepman Auditory Discrimination Test Wepmans Auditory Memory Battery Western Aphasia Battery Western Personality Inventory Whitaker Index of Schizophrenic Thinking (WIST) Wide Range Achievement Test 3rd Edition (WRAT-3) Wide Range Achievement Test 4th Edition (WRAT-4) IQ Academic Skills Academic Skills IQ-Multitask Neuro: Memory IQ-Multitask Educational Beh Rating Scale Neuro/LD: Language Memory-LD Neuro: Language Chemical Dep Symptom Screen Neuro/Educational Neuro/Educational TYPE AGE 16-74 12+ 5-12 6-16 16 89 3-7 16-89 Adult 4-8 58 Adol+ 18+ 16+ 5+ 5+ MINUT ES 60 45 45 135 75 120 15 15 20 15 75 15 15 30 40/60 40 min for 5-7 yr olds/60 min for 8+; Admin time varies depending on the age of child: 15 to 25 minutes for ages 5 to 7 years and 35 to 45 minutes for ages 8+. 15 minutes added for scoring and write-up. 10-15 minutes screening version available 8th grade education and normal IQ COMMENTS May be appropriate for screening Screening version .5 hr. Screening version .5 hr.

Wide Range Assessment of Memory & Learning (WRAML) Wide Range Assessment of Visual Motor Abilities (WRAVMA) Wisconsin Card Sorting Test (WCST) Woodcock-Johnson Psychoeduca Battery (Achievement) Woodcock-Johnson Psychoeduca Battery (Cognitive) Woodcock Language Proficiency Battery-R Woodcock Reading Mastery Tests-R Working Memory Test Battery for Children Yale-Brown Obsessive Compulsive Scale Yale Food Addiction Scale Zung Depression Index

Neuro/Educational Neuro/Educational Neuro: Academic Skills Cognitive/IQ Language Academic Skills Neuro; Educational Personality Personality Rating Scale

5-17 3-17 12+ 2+ 2+ 2 adult 5 75 5-15 Adult Adult Adult

60 45 45 90 90 60 60 60 15 15 5

Needs IQ or HALTEAD AS REFERENCE 1.5 for Standard Battery/2.0 for Standard & Supp. 1.5 for R Standard Battery/2.0 for Standard & Supp.

Reported out of print effective 1/2011

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 14 of 15

Purpose of Testing and Influence on Treatment Diagnostic clarification; rule-out co-morbidities consistent with the American Academy of Child and Adolescent Psychiatry practice parameters regarding inclusion of objective screening measures from multiple sources. Treatment planning; modalities to use, challenges likely to be faced in therapy, etc. Gather information to assess if medication is indicated.

3.704.3 Revised 12/08/05, 12/14/06; 12/13/07; 11/01/09, 11/18/09, 11/21/11 15 of 15