Get Nevada Medicaid And Nevada Check Up Rehabilitation Fa-11a Authorization Request

This guide provides comprehensive instructions for completing the Nevada Medicaid and Nevada Check Up Rehabilitation FA-11A Authorization Request online. By following the steps outlined below, users can efficiently and accurately fill out the necessary sections of the form.

Follow the steps to complete the authorization request form online.

1. Press the ‘Get Form’ button to access the Nevada Medicaid and Nevada Check Up Rehabilitation FA-11A Authorization Request form digitally.
2. Enter the recipient's identification details, including their name, date of birth, and Medicaid ID number, in the designated fields.
3. Fill in the 'Request Date' with the date on which you are submitting the request.
4. Specify the type of request you are making by selecting one of the following options: concurrent authorization, reconsideration, unscheduled revision, or retrospective authorization.
5. Provide information about the coordinating QMHP by entering their name, credentials, NPI, and contact information.
6. Complete the requesting provider section by including their name, credentials, NPI, phone number, and fax number.
7. Document the recipient's living arrangements and indicate if they are in State custody, along with the custody date if applicable.
8. In the ICD-10 diagnosis section, enter the primary diagnosis code and disorder, along with any secondary and tertiary codes if applicable.
9. Document the assessment scores and levels for relevant assessments like CASII, LOCUS, or ECSII in the designated fields.
10. List any significant life events or symptoms that pertain to the recipient's diagnosis in the symptoms section.
11. Outline the treatment plan and rationale, identifying goals for each problem or behavior and any progress made.
12. Enter details about the current medications being taken, including medication names and dosages, and attach additional sheets if necessary.
13. Describe previous treatments relevant to the recipient’s psychiatric and medical conditions.
14. Specify the requested and approved treatment details, including service codes, modifiers, durations, and totals required.
15. Indicate the service limits by confirming whether units above the established limits are being requested and provide relevant treatment histories as required.
16. Once all sections are filled out, review the information for accuracy. You can then save your changes, download, print, or share the completed form as necessary.

Complete your documents online for a seamless submission process.