Fillable Outpatient Rehabilitation and Therapy (State of Nevada, Department of Information Technology)

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Outpatient Rehabilitation and Therapy (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
Page 1 of 2 FA-7
01/29/2019 (pv10/30/2018)
Outpatient Rehabilitation and Therapy
Upload through the Provider Web Portal.
For questions regarding this form, call: (800) 525-2395
Required documentation which must be uploaded and submitted with this form:
Plan of Care (POC) must include deficits, chronic or acute, short-term and long-term goals, end goal
and progress toward goals
Doctor’s order
Authorization is limited to a 90-day period for recipients age 21 and older and a 180-day period for recipients
under age 21. If the doctor’s order is for one year, the same order can be attached.
DATE OF REQUEST: ________/________/_________
REQUEST TYPE: Prior Authorization Continued Services Retrospective Review
REQUIRED FOR RETROSPECTIVE REVIEWS ONLY
This recipient was determined eligible for Medicaid benefits on:
______ /______ /________
NOTES:
RECIPIENT INFORMATION
Recipient Name (Last, First, MI):
Recipient ID:
DOB:
Phone:
Address (include city, state, zip):
Guardian Name (if applicable):
Guardian Phone:
Medicare Insurance Information: Part A Part B Medicare ID#:
Other Insurance Name: Other Insurance ID#:
ORDERING PROVIDER INFORMATION
Ordering Provider Name:
NPI:
Fax:
Address (include city, state, zip):
Contact Name:
SERVICING PROVIDER INFORMATION
Servicing Provider Name:
NPI:
Fax:
Address (include city, state, zip):
CLINICAL INFORMATION Use additional sheet(s) if needed to submit all pertinent medical
documentation and justification to be considered in the determination of this request.
Is this request for Healthy Kids (EPSDT) referral/services? Yes No
Diagnosis (include ICD-10 codes and descriptions):
Prior Authorization Request
Nevada Medicaid and Nevada Check Up
Outpatient Rehabilitation and Therapy
Page 2 of 2 FA-7
01/29/2019 (pv10/30/2018)
REQUESTED SERVICES (enter one code per line)
CPT Code and Description
Units Requested
per Week
Number of
Weeks
1.
2.
3.
4.
Functional Deficits and Rehabilitation Diagnoses:
Treatment Goals:
Previous Service or Treatment and Outcome or Results (include dates of prior services and an explanation of
any non-compliance):
Other Clinical Information Supporting the Medical Necessity of Requested Services:
This referral/authorization is not a guarantee of payment. Payment is contingent upon eligibility, benefits available at the time the service is rendered,
contractual terms, limitations, exclusions, coordination of benefits and other terms and conditions set forth by the benefit program. The information
contained in this form, including attachments, is privileged, confidential and 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 has been received in error, the reader shall
notify sender immediately and shall destroy all information received.
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Outpatient Rehabilitation and Therapy (State of Nevada, Department of Information Technology)

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Completed 7 September 2021

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