Nevada Medicaid and Nevada Check Up News (Third Quarter 2019 Provider Newsletter) [Read]

Behavioral Health Providers Invited to Attend Monthly DHCFP Webinars [See Web Announcement 1628]

Attention All Providers: Requirements on When to Use the National Provider Identifier (NPI) of an Ordering, Prescribing or Referring (OPR) Provider on Claims [Announcement 850]

If you are a Medicaid provider whose revalidation application has not been processed by your termination due date, you will be ineligible to provide services to any Nevada Medicaid or Nevada Check Up recipients, including both Fee-for-Service and Managed Care Organization (MCO) enrolled recipients. See Web Announcement 1265

Enrollment Termination Frequently Asked Questions (FAQs) [Review]

Notifications


Known Modernization System Issues-Click HERE

Top 10 Claim Denial Reasons and Resolutions/Workarounds for August 2019 Claims. See Web Announcement 1979.

Paper claims are no longer accepted by Nevada Medicaid. Please refer to Web Announcement 1733 and Web Announcement 1829 for additional information.

Attention Providers Using the Authorization Criteria Function: Results that return prior authorization (PA) requirements are accurate. For results that return “There are no records found based on the search criteria,” there may be a PA requirement if limits have been exceeded. To verify PA requirements, please refer to the Medicaid Services Manual (MSM) Chapter for your service type at dhcfp.nv.gov and the Billing Guide for your provider type at www.medicaid.nv.gov.

Scheduled Site Maintenance

During the scheduled site maintenance window the Provider Web Portal will be unavailable. The table below shows the regularly scheduled maintenance window. All times will be in the Pacific time zone.

Monday - Friday
12:00AM - 12:30AM

Monday
8:00PM - 12:00AM

Nevada Medicaid Forms Can Now Be Submitted Using the Provider Web Portal


On July 6, 2015, Nevada Medicaid completed updating all of the Nevada Medicaid forms that are available on this website. These forms have been updated to a format that allows them to be completed, downloaded and saved electronically. In addition, an enhancement has been made to allow some forms to be submitted online using the “Upload Files” page on the Provider Web Portal.


Please see Web Announcement 938 for the list of forms that can be uploaded using the “Upload Files” page on the Provider Web Portal, the types of forms that may not be uploaded, and screenshots and instructions for uploading forms. Upload instructions are also available in the new Electronic Verification System (EVS) User Manual Chapter 8.

Prior Authorization Forms

All prior authorization forms are for completion and submission by current Medicaid providers only.

Form Number Title
FA-1 Durable Medical Equipment Prior Authorization Request
FA-1A Usage Evaluation for Continuing Use of BIPAP and CPAP Devices
FA-1B Mobility Assessment and Prior Authorization (PA)
FA-1B Instructions Mobility Assessment and Prior Authorization (PA) Instructions
FA-1C Oxygen Equipment and Supplies Prior Authorization Request
FA-1D Wheelchair Repair Form
FA-3 Inpatient Rehabilitation Referral/Assignment
FA-4 Long Term Acute Care Prior Authorization
FA-6 Outpatient Medical/Surgical Services Prior Authorization Request
FA-7 Outpatient Rehabilitation and Therapy Services Prior Authorization Request
FA-8 Inpatient Medical/Surgical Prior Authorization Request
FA-8A Induction of Labor Prior to 39 Weeks and Scheduled Elective C-Sections
FA-9 Ocular Services or Medical Nutrition Therapy Services Prior Authorization Request
FA-10A Psychological Testing
FA-10B Neuropsychological Testing
FA-10C Developmental Testing
FA-10D Automated Testing
FA-11 Behavioral Health Outpatient or Rehabilitative Authorization Request
FA-11B Mental Health Request for PHP/IOP Services (Partial Hospitalization Program and Intensive Outpatient Program)
FA-11D Substance Abuse/Behavioral Health Authorization Request
FA-11E Applied Behavior Analysis (ABA) Authorization Request
FA-11F Autism Spectrum Disorder (ASD) Diagnosis Certification for Requesting Initial Applied Behavior Analysis (ABA) Services
FA-12 Inpatient Mental Health Prior Authorization
FA-13 Residential Treatment Center Concurrent Review
FA-13A RTC Absence Form
FA-14 Inpatient Mental Health Services Concurrent Review Request
FA-15 Residential Treatment Center Prior Authorization
FA-16A Home Health Agency – Intermittent Services Prior Authorization Request
FA-16A Instructions Home Health Agency – Intermittent Services Prior Authorization Request Instructions
FA-16B Home Health Agency – Private Duty Nursing (PDN) Services Only Prior Authorization Request
FA-16B Instructions Home Health Agency – Private Duty Nursing (PDN) Services Only Prior Authorization Request Instructions
FA-17 Adult Day Health Care Services Prior Authorization Request
FA-18 Level 1 Identification Screening for PASRR
FA-19 Level of Care Assessment for Nursing Facilities
FA-19 Instructions Level of Care Assessment for Nursing Facilities Instructions
FA-20 PASRR and LOC Copy Request
FA-21 PASRR and LOC Data Correction Form
FA-22 Screening Request for Pediatric Specialty Care Services
FA-24 Personal Care Services (PCS) Prior Authorization | PCS Assessment Forms
FA-24 Instructions Personal Care Services (PCS) Prior Authorization Instructions
FA-24A Coordination of Hospice and Waiver or Personal Care Services (PCS)
FA-24A Instructions Coordination of Hospice and Waiver or Personal Care Services (PCS) Instructions
FA-24B Legally Responsible Individual (LRI) Availability Determination for the Personal Care Services Program
FA-24C Authorization Request for Self-Directed Skilled Services
FA-24C Instructions Authorization Request for Self-Directed Skilled Services Instructions
FA-24T Personal Care Services Recipient Request for Provider Transfer
FA-25 Orthodontic Medical Necessity (OMN) Form
FA-26 Client Treatment History Form (For Medicaid Orthodontic Treatment)
FA-29 Prior Authorization Data Correction Form
FA-29A Request for Termination of Service
FA-29B Prior Authorization Reconsideration Request
FA-30 Out-of-State Nursing Facility Placement Packet
FA-30-I Out-of-State Nursing Facility Placement Packet Instructions
Dental PA Instructions Instructions for Submitting Dental Prior Authorization Requests Using the 2012 ADA Dental Form

Enrollment Forms

Enrollment forms are for completion and submission only by providers applying for enrollment in the Nevada Medicaid and Nevada Check Up program.

Form Number Title
FA-34 Provider Voluntary Termination Notice


Sterilization/Abortion Forms

Sterilization/Abortion forms are for completion and submission by current Medicaid providers only.

Form Number Title
FA-50 Nevada Medicaid Hysterectomy Acknowledgement Form
FA-52 Abortion Affidavit (Rape)
FA-53 Abortion Affidavit (Incest)
FA-54 Abortion Declaration (Rape)
FA-55 Abortion Declaration (Incest)
FA-56 Sterilization Consent
FA-57 Certification Statement for Abortion to Save the Life of the Mother

Pharmacy Forms

Pharmacy forms are for completion and submission by current Medicaid providers only.

Form Number Title
FA-59 Pharmacy Authorization
FA-60 MAC Pricing Appeal Form
FA-61 Actemra® (tocilizumab)
FA-62 Request for Pharmaceutical Product Review
FA-63 PDL Exception Prior Authorization
FA-64 Cox-II Prior Authorization
FA-65 Synagis® Prior Authorization
FA-66 Amevive® (alefacept)
FA-67 Growth Hormones For Recipients Under Age 21 Prior Authorization
FA-68 ADHD Treatment For Recipients Age 18 And Above
FA-69 ADHD Treatment For Recipients Under 18
FA-70A Psychotropic Agents for Children Age 0 to 5
FA-70B Psychotropic Agents for Children and Adolescents Ages 6 to 18
FA-71 Multiple Sclerosis – Ampyra® Prior Authorization
FA-72 Topical Androgen Agents
FA-73 Bunavail®, buprenorphine, buprenorphine-naloxone, Suboxone®, Zubsolv®
FA-74 Makena® (hydroxyprogesterone caproate injection)
FA-76 Cimzia® (certolizumab pegol)
FA-77 Targeted Immunomodulators
FA-78 Kineret® (anakinra)
FA-79 Orencia® (abatacept)
FA-80 Remicade® (infliximab)
FA-81 Simponi® (golimumab)
FA-82 Stelara® (ustekinumab)
FA-83 Xolair® (omalizumab)
FA-84 Cesamet® (nabilone)
FA-85 Forteo® (teriparatide)
FA-86 Marinol® (dronabinol)
FA-87 Prolia® (denosumab)
FA-88 Opioid Quantity Limit
FA-89A Third Generation Cephalosporins and Fluoroquinolone
FA-89B Tedizolid (Sivextro®)
FA-89C Linezolid (Zyvox®)
FA-150 Compounded Medication
FA-151 Calcitonin Gene-Related Peptide (CGRP) Receptor Inhibitor Medications
FA-152 Epidiolex®(Cannabidiol)
FA-153 Opioids Prescribed to Under Age 18
FA-154 Pulmonary Arterial Hypertension Agents
FA-155 Oral Oncology Agents
FA-156 Short-Acting Bronchodilator Quantity Limit
FA-157 Immunomodulator Drugs
FA-158 Xyosted™

Appeals Forms

Appeals forms are for completion and submission by current Medicaid providers only.

Form Number Title
FA-90 Formal Claim Appeal Request

Hospice Forms

The following forms are for the use of Nevada Medicaid Hospice providers.

Form Number Title
FA-91 Nevada Medicaid Hospice Program Action Form
FA-92 Nevada Medicaid Hospice Program Election Notice - Adults
FA-93 Nevada Medicaid Hospice Program Election Notice - Pediatric
FA-94 Nevada Medicaid Hospice Program Physician Certification of Terminal Illness
FA-95 Nevada Medicaid Hospice Prior Authorization Request
FA-96 Nevada Medicaid Hospice Extended Care Physician Review Form

Emergency Dialysis Case Certification Forms

The following forms are for the use of Nevada Medicaid and Nevada Check Up providers to certify that a non-United States citizen has met the medical conditions to be eligible to receive outpatient emergency End Stage Renal Disease (ESRD) services through the Federal Emergency Services (FES) program.

Form Number Title
FA-100 Initial Emergency Dialysis Case Certification
FA-101 Monthly Emergency Dialysis Case Certification

Nevada DHCFP Forms

The following forms are for the use of Nevada Medicaid and Nevada Check Up providers.

Form Number Title
NMO-7073 Functional Assessment Service Plan
NMO-7073 Instructions Functional Assessment Service Plan Instructions
NMO-7073 (SP) Functional Assessment Service Plan (Spanish)
NMO-7073 Instructions (SP) Functional Assessment Service Plan Instructions (Spanish)
NMO-3430A Nevada DHCFP Serious Occurrence Report
NMO-3430A Instructions Nevada DHCFP Serious Occurrence Report Instructions
SOR Nevada DHCFP Serious Occurrence Report (Web-based Version)
SOR Instructions Nevada DHCFP Serious Occurrence Report Instructions (Web-based Version)