FA-29: Nevada Medicaid and Nevada Check Up Prior Authorization Data Correction Form

FA-29 PDF Details

This form cannot be used to request re-determination of medical necessity, nor does it take the place of a prior authorization request.

Processing: please allow up to 30 days for processing.

Attachments: attachments are not required with this form.

Upload: upload this form through the Provider Web Portal.

Authorization number: fill in the 11-digit Authorization Number assigned to your original request.

Questions: if you have any questions, please call (800) 525-2395.