Fillable Durable Medical Equipment (State of Nevada, Department of Information Technology)

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Durable Medical Equipment (State of Nevada, Department of Information Technology)

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BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

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Prior Authorization Request
Nevada Medicaid and Nevada Check Up
Durable Medical Equipment
FA-1 Page 1 of 2
10/27/2021 (pv01/29/2019)
Upload this request through the Provider Web Portal.
For questions regarding this form, call: (800) 525-2395.
DATE OF REQUEST: ______ /______ /________
REQUEST TYPE: Initial Continued Services Retrospective Unscheduled Revision
REQUIRED FOR RETROSPECTIVE REQUESTS ONLY
This recipient was determined eligible for Medicaid benefits on:
______ /______ /________
NOTES:
RECIPIENT INFORMATION
Recipient Name (Last, First, MI):
Recipient ID:
Phone:
DOB:
Address:
City:
State:
Zip Code:
INSURANCE INFORMATION
Medicare: Part A Part B ID#: ____________________ Other Insurance: _______________________
Additional Comments:_______________________________________________________________________
Does this recipient meet the standard Medicare criteria for the requested items? Yes No
(If “No,” PA will be processed. The provider agrees to obtain a signed ABN for any service Medicare does not
cover due to medical necessity.)
ORDERING PROVIDER INFORMATION
Ordering Provider Name:
Phone:
Fax:
Address:
City:
State:
Zip Code:
SERVICING PROVIDER INFORMATION
Servicing Provider Name:
Phone:
Fax:
Address:
City:
State:
Zip Code:
Contact Name:
CLINICAL INFORMATION
Enter up to four ICD codes that apply: ____________ ____________ ____________ ___________
Additional Clinical Information:
Prior Authorization Request
Nevada Medicaid and Nevada Check Up
Durable Medical Equipment
FA-1 Page 2 of 2
10/27/2021 (pv01/29/2019)
In the table below, use column 1 to enter the HCPCS code. Check column 2 if no HCPCS code is assigned from
PDAC for the item being requested. Use column 3 to enter a description of the item. Enter the appropriate
modifier and number of requested units in columns 4 and 5. In column 6, enter “R” if the equipment is for rent
and “P” if the equipment is for purchase. If the item is covered by Medicare, enter a “Y” in column 7. If the item
is not covered by Medicare, enter an “N” in column 7. Enter the requested “Start” and “End” dates for each item
in columns 8 and 9.
1
2
3
4
5
6
7
8
9
HCPCS CODE
No HCPCS code
DESCRIPTION
MODIFIER
UNITS
“ R” or “ P”
MEDICARE
Y or N
START DATE
END DATE
Is this request for Healthy Kids (EPSDT) services? Yes No
REQUIRED FOR NURSING FACILITY (NF) PATIENTS AND PATIENTS BEING DISCHARGED FROM A NF:
Enter the date the recipient was or will be discharged from the nursing facility: ______ /______ /_______
ORDERING PHYSICIAN’S SIGNATURE:________________________________________________________
(Must match the Ordering Provider indicated on page 1 of this form.)
PRINT NAME: DATE: ______ /______ /________
THE FOLLOWING FIVE ITEMS MUST BE ATTACHED TO THIS FORM:
(1) documentation of medical necessity from the servicing provider, (2) a medical order from the
servicing provider, (3) a copy of the signed prescription, (4) the unaltered complete order form specific
to the manufacturer and the model of the items being requested, (5) a copy of the equipment
manufacturer’s invoice, when applicable, and (6) documentation of face-to-face clinical visit with the
prescribing practitioner, relevant to the equipment/supplies requested, and within 30 to 60 days of the
prescription.
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.
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Durable Medical Equipment (State of Nevada, Department of Information Technology)

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Completed 30 December 2022

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