Form Fa 29 Nevada PDF Details

In the realm of healthcare services facilitated by Nevada Medicaid and Nevada Check Up, the importance of accurate administrative data cannot be overstated. The FA-29 Nevada form plays a crucial role in ensuring that non-clinical, administrative data related to prior authorization requests are correctly captured and updated as necessary. Designed specifically for the purpose of correcting or modifying such data that was previously submitted, it serves as an essential administrative tool for healthcare providers. It is important to note that this form is not intended for re-determining medical necessity or as a substitute for the initial prior authorization request. Instead, it offers a streamlined process to rectify errors or changes in service type, provider information, and recipient details, without the need for re-submitting clinical documentation. Providers are advised to allow up to 30 days for the processing of the FA-29 form and reminded that all medical necessity documentation must accompany the original authorization request. Furthermore, the form includes provisions for indicating the service type in question, from Adult Day Health Care (ADHC) and Behavioral Health to various medical, surgical, and therapeutic services. Completing and faxing this form to the specified number, along with detailed reasons for the data modification, ensures the timely and accurate processing of prior authorization data, ultimately supporting the efficient delivery of healthcare services to recipients in Nevada.

QuestionAnswer
Form NameForm Fa 29 Nevada
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmedicaid fa29 form, ADHC, Nevada, fa29 form medicaid

Form Preview Example

+3 ( QWHUSU VH 6 HUY FHV - Nevada Medicaid and Nevada Check Up

PRIOR AUTHORIZATION DATA CORRECTION FORM

Purpose: Use this form to correct or modify non-clinical, administrative data on a previously submitted prior authorization request. This form cannot be used to request re-determination of medical necessity, nor does it take the place of a prior authorization request. Please allow up to 30 days for processing.

Attachments: Attachments are not required with this form. Documentation to fully support medical necessity must be submitted with the prior authorization request and be available in the recipient’s medical record.

Fax this form to: (866) 480-9903

Questions: If you have any questions, please call +3 ( QWHUSU VH 6 HUY FHV at (800) 525-2395.

Submission Date of This Form:

 

 

Date(s) of Service:

 

 

 

 

 

 

 

 

Are you an out of state provider?

No

Yes

Does TPL exist?

No

Yes

 

 

 

 

 

 

SERVICE TYPE Indicate the type of service for which you are requesting a data correction.

ADHC

Behavioral Health

DME

Home Health

 

Inpatient Medical/Surgical

Inpatient LTAC

Inpatient Rehab

 

Outpatient Medical/Surgical

Outpatient Rehab

Outpatient Therapy

RTC

AUTHORIZATION NUMBER

 

 

 

 

 

11-digit Authorization Number assigned to your original request:

 

BILLING PROVIDER INFORMATION

 

 

 

 

Provider Name:

 

 

NPI:

 

 

 

Contact Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

Fax:

 

 

 

 

 

 

 

 

 

INFORMATION TO MODIFY

 

 

 

 

 

What non-clinical data on your original request should be modified?

 

 

 

 

 

 

 

 

 

 

 

 

 

Why should this data be modified?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECIPIENT INFORMATION

 

 

 

 

 

Recipient Name:

 

 

 

 

 

Date of Birth:

 

 

 

 

Recipient ID:

 

 

 

 

 

 

Admission Date or Begin Date of Service:

 

 

Discharge Date:

 

 

 

 

 

 

HP ENTERPRISE SERVICES USE ONLY

 

 

 

 

Name:

Comments:

Signature:

FA-29

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10/01/11

 

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