Universal Referral Form Nevada – Fill Out and Use This PDF

Universal Referral Form Nevada PDF Details

The Nevada Universal Prior Authorization Form (Revised 9/5/19, S4590) requests a referral or prior authorization for the plans listed on the form: Health Plan of Nevada (Nevada Exchange, HPN POS tiers, HPN Medicaid) and Sierra Health and Life. All sections must be completed. It asks for the date of request, the primary care provider, the requesting provider's details, tax ID and signature, the member's name, number, address and date of birth, other insurance, the diagnosis with ICD-10 code, the procedure or treatment with CPT code, the service provider, the place of service and the requested date. Clinical information such as progress reports, laboratory results and imaging studies must be attached to prevent processing delays. The form states that the referral or authorization is not a guarantee of payment, and that a reconsideration or expedited appeal may be requested on adverse determinations.