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.
Attention Pharmacies: Emergency Supply Policy
In an emergency situation, dispensing of up to a 96-hour supply of covered outpatient drugs that require prior authorization (PA) will be allowed. An approved PA (if required) will be necessary to get additional medication. If the prescriber is not available and the pharmacist feels the recipient needs to receive the prescribed drug, the pharmacist should contact the Clinical Call Center at (855) 455-3311 or the Technical Call Center at (866) 244-8554. OptumRx, the pharmacy benefit manager, may authorize a 96-hour emergency supply.
NOTE: An emergency situation is a situation that, in the judgment of the dispensing pharmacist, involves an immediate threat of severe adverse consequences to the recipient, or the continuation of immediate and severe adverse consequences to the recipient, if an outpatient drug is not dispensed when a prescription is submitted.
The Emergency Supply Policy is specified in the Medicaid Services Manual (MSM) Chapter 1200 Prescribed Drugs and the Pharmacy Billing Manual.
Pharmacy PA Forms
Pharmacy forms are for completion and submission by current Medicaid providers only. Use the forms below to request prior authorization. Attach documentation to support the request as needed. If you have questions, call Nevada Medicaid at (800) 525-2395.
Other Pharmacy Forms
Pharmacy forms are for completion and submission by current Medicaid providers only.
|FA-60||MAC Pricing Appeal Form|
|FA-62||Request for Pharmaceutical Product Review|
Diabetic Supply Forms
|FA-200||Continuous Glucose Monitors (CGMs) Prior Authorization Request Form|
|FA-201||Tubeless Insulin Pump Prior Authorization Request Form|
Nevada DHCFP Form
|NMO-4||Request for Pharmacy Change for Lock-In Recipients|