Get Nv Fa-63 2017-2025

The NV FA-63 is a form used for prior authorization requests for non-preferred drugs under the Nevada Medicaid program. This guide provides clear instructions on how to complete the form online, ensuring that your request is accurate and complete for optimal processing.

Follow the steps to successfully complete the NV FA-63 online

1. Press the ‘Get Form’ button to obtain the NV FA-63 form and open it in your preferred format for editing.
2. Fill in the date of request to indicate when the prior authorization is being submitted.
3. Complete the recipient information section: provide the last name, first name, middle initial, date of birth, recipient ID, gender, and phone number.
4. In the prescribing provider information area, enter the provider's name, NPI number, phone number, and fax number. Include the name of the person to contact regarding this request.
5. In the diagnosis and requested drug section, fill in the applicable ICD-10 code along with the diagnosis or symptom/side effect. Specify the requested drug name, strength, dosage, and duration. Note that generic substitution is not permitted.
6. In the clinical information section, explain the recipient’s history of allergies or side effects related to preferred medications, and list any preferred medications that have been tried and failed with reasons and dates.
7. Indicate any contraindications or potential drug interactions with the preferred medications, and add any additional clinical information if applicable.
8. Check the applicable boxes to confirm whether the non-preferred drug is being requested for a unique indication and if the member was recently discharged from a mental health facility, including the discharge date.
9. Complete the provider certification area by obtaining the prescriber’s signature and date to confirm the treatment is necessary and meets Nevada Medicaid guidelines.
10. Once all fields are completed, save the changes, and consider downloading, printing, or sharing the form as needed.

Start completing your NV FA-63 form online today to ensure your prior authorization request is processed efficiently.