Get Fax Transmittal Sheet Nevada Medicaid And Nevada Check Up Substance Abuse/bh Fa11d Authorization

Completing the Fax Transmittal Sheet for Nevada Medicaid and Nevada Check Up Substance Abuse/BH FA11D Authorization is an essential step for ensuring that service authorizations are processed efficiently. This guide provides clear instructions for filling out the form online, making the submission process as straightforward as possible.

Follow the steps to complete the form for online submission.

1. Click ‘Get Form’ button to obtain the form and open it in the editing tool.
2. Fill in the ‘To’ section with the recipient information, including the organization name (Hewlett Packard Enterprise NV MH Outpatient Program) and the fax number (866) 480-9903. Provide your name, fax number, and phone number in the ‘From’ section.
3. Complete the date, indicating when you are filling out the form, and state the total number of pages included in the fax.
4. Mark the necessary checkboxes for urgency, approval requests, and comments, if applicable.
5. Provide the request date and select the request type (initial prior authorization, concurrent authorization, unscheduled revision, reconsideration, or retrospective authorization). Fill in applicable start dates or eligibility decisions.
6. In Section I (Prescribing Provider), enter the provider's name, credentials, phone, fax, and address.
7. In Section II (Requesting Provider), input the group name and NPI number, along with the contact phone and fax.
8. Complete the recipient's information in Section III, which includes their name, date of birth, Medicaid ID, age, and living arrangements. Indicate if the recipient is in state custody and provide relevant dates.
9. Fill out Section IV (Responsible Party) with the name, phone, address, and relationship to the recipient.
10. In Section V (ICD-10 Diagnosis), provide primary, secondary, and tertiary diagnosis codes along with the corresponding disorders.
11. For Section VI, list all substances used in the past 90 days along with details regarding the severity of use and laboratory test results, if available.
12. Sections VII to XII require detailed assessments on levels of care, psychiatric issues, client progress, treatment plans, medications, and previous treatments. Complete these sections thoughtfully with comprehensive information.
13. In Section XIII, list the requested treatment services, providing details including code, modifiers, provider name, start and end dates, and contact details for the requester.
14. Finally, ensure all sections are completed, review for accuracy, and then save changes, download, print, or share the form as needed.

Complete your documents online today to ensure timely processing of your requests.