Nevada Form Fa 6 PDF Details

In the realm of healthcare administration, managing and understanding the complexities of forms and authorizations is crucial, particularly for those navigating the systems of Nevada Medicaid and Nevada Check Up. The Nevada FA-6 form plays a pivotal role in this process, serving as a Prior Authorization Request for outpatient medical and surgical services. This document, designed by HP Enterprise Services, functions as the gateway for healthcare providers to secure approval before delivering certain types of healthcare services. Key features of the form include sections for recipient information—comprising personal and insurance details—and comprehensive sections for ordering and servicing provider information. With the FA-6, healthcare professionals are required to detail the clinical information supporting their request for service(s), including the service code, units requested, and a thorough description. Significantly, this form distinguishes between various types of requests such as initial services, continued services, retrospective reviews, unscheduled, and revisions, thereby covering a spectrum of healthcare scenarios. It is important to note that inclusion of prior treatment outcomes, if applicable, and the notification that authorization does not guarantee payment underscores the form’s role in the larger context of healthcare administration and insurance protocols. Additionally, for those seeking reimbursement or authorization for outpatient rehabilitation and therapy services, the FA-7 form is specified as the correct document, indicating the specialized nature of the Nevada FA-6 form. As such, understanding and correctly completing the Nevada FA-6 form is essential for healthcare providers aiming to navigate the Medicaid system efficiently, ensuring that necessary services are both authorized in a timely manner and align with the overarching regulations and requirements set forth by Nevada Medicaid and Nevada Check Up programs.

QuestionAnswer
Form NameNevada Form Fa 6
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesapplicable, EPSDT, Nevada, contractual

Form Preview Example

Prior Authorization Request

HP Enterprise Services - Nevada Medicaid and Nevada Check Up

Outpatient Medical/Surgical

(Use Form FA-7 for Outpatient Rehabilitation and Therapy Services)

Fax this request to:

(866) 480-9903

For questions regarding this form, call: (800) 525-2395

DATE OF REQUEST: ______ /______ /________

 

 

REQUEST TYPE:

Initial

Continued Services

Retrospective*

Unscheduled Revision

*REQUIRED FOR RETROSPECTIVE REVIEWS ONLY

This recipient was determined eligible for Medicaid benefits on: ______ /______ /________

RECIPIENT INFORMATION

Recipient Name (Last, First, MI):

Recipient ID:

 

 

 

DOB:

Address:

 

 

 

Phone:

City:

 

State:

 

Zip Code:

Medicare Insurance Information:

Part A

Part B

Medicare ID#:

Other Insurance Name:

 

 

Other Insurance ID#:

Responsible Party Name (if applicable):

Responsible Party Address:

Phone:

ORDERING PROVIDER INFORMATION

Ordering Provider Name:

NPI:

Address:

City:

 

 

 

 

 

State:

 

 

 

Zip Code:

Phone:

 

 

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

Contact Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERVICING PROVIDER INFORMATION

 

 

 

 

 

 

 

 

 

 

Servicing Provider Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

State:

 

 

 

Zip Code:

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

Contact Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLINICAL INFORMATION (attach additional sheets if necessary)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No. of

 

 

 

 

 

 

 

 

 

HP ENTERPRISE

 

 

Code

 

 

 

 

 

 

 

 

 

 

SERVICES USE ONLY

 

 

 

 

Units

 

 

Description of Service

 

 

 

 

 

 

 

 

 

 

 

Requested

 

 

 

 

 

 

Units

 

 

 

 

 

 

 

 

 

Requested

 

 

 

 

 

 

 

 

 

Status

 

Action Code

 

 

 

 

 

 

 

 

 

 

 

 

Approved

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FA-6

Page 1 of 2

10/01/11

 

 

Prior Authorization Request

HP Enterprise Services - Nevada Medicaid and Nevada Check Up

Outpatient Medical/Surgical

(Use Form FA-7 for Outpatient Rehabilitation and Therapy Services)

Is the service you are requesting a hospice benefit?

Yes

No

 

Are you requesting Healthy Kids (EPSDT) referral/services?

Yes

No

Conditions/Symptoms (include ICD-9 codes and descriptions):

 

 

Previous Treatment/Services (include dates):

Results of Previous Treatment/Services:

Other Clinical Information (to support medical necessity of the requested services):

HP ENTERPRISE SERVICES USE ONLY

Approved From:

Approved Through:

Denied From:

Denied Through:

Reviewer Signature:

 

Date:

This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions, coordination of benefits and other terms and conditions set forth by the benefit program. The information on this form and on accompanying attachments is privileged and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the employee or agent responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If this communication is received in error, the reader shall notify sender immediately and destroy all information received.

 

 

 

FA-6

Page 2 of 2

10/01/11

 

 

How to Edit Nevada Form Fa 6 Online for Free

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Writing part 1 of applicable

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Filling out part 2 in applicable

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Step number 3 of filling in applicable

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applicable conclusion process clarified (stage 4)

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Stage no. 5 of filling out applicable

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