Form FA-1B "Mobility Assessment and Prior Authorization (Pa) Request for Mobility Devices, Wheelchair Accessories and Seating Systems" - Nevada

What Is Form FA-1B?

This is a legal form that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on October 27, 2021;
  • The latest edition provided by the Nevada Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FA-1B by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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Nevada Medicaid and Nevada Check Up
Mobility Assessment and Prior Authorization (PA) Request
For Mobility Devices, Wheelchair Accessories and Seating Systems
Upload this request through the Provider Web Portal.
Questions? Call: (800) 525-2395
Before completing this form, refer to the detailed instructions (FA-1B-I).
**Completion of this form does not guarantee approval or reimbursement for the items requested.**
NOTES:
SECTION I: PRIOR AUTHORIZATION (PA) INFORMATION
(This section to be completed by the Medicaid provider requesting PA.)
1. PA Request Date:
2. Assessment Date:
3. Prescription/Order Date:
4. Request Type:
Initial
Continued Services
Retrospective
Unscheduled Revision
5. For “retrospective” requests only, enter the Medicaid Eligibility Determination Date:
6. For children under age 21 only, is this request a result of, or pursuant to Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) Healthy Kids services?
Yes
No
Unknown
RECIPIENT INFORMATION (Recipient name must match Medicaid card/records.)
7. Name (last, first):
8. Recipient ID:
9a. Date of Birth:
9b. Age: ____ years ____ months
10. Sex:
Female
Male
11. Phone:
12. Address (include city, state and zip):
13. Recipient’s place of residency
Hospital
Nursing Facility
ICF / MR
Group Home
Assisted Living
Private Home
Apartment
Temporary Lodging
Other (specify):
Length of Residency:_________________________________________
14. For recipients in or being discharged from a medical facility, enter actual or anticipated discharge date:
15a. Check all that apply and provide identification numbers as applicable:
The recipient is covered by:
Medicare Part A
Medicare Part B
Medicare Number: ____________________
Other Insurance Name (if applicable):
Group ID Number: ____________________
15b. Does this recipient meet the standard Medicare criteria for the requested item(s)?
Yes
No
Not applicable
(If “No”, PA will be processed. The provider agrees to obtain a signed Advance Beneficiary Notice (ABN) for any
services Medicare does not cover due to medical necessity.)
ORDERING PHYSICIAN/PRACTITIONER INFORMATION (Must be treating physician)
16. Name:
17. NPI:
18. Address (include city, state and zip):
19. Phone:
20. Fax:
21. Contact Name:
SERVICING DME PROVIDER / SUPPLIER INFORMATION
(This section may be completed by any Medicaid provider involved in this request.)
22. Name:
23. NPI:
24. Address (include city, state and zip):
25. Phone:
26. Fax:
27. Contact Name:
Updated 10/27/2021
FA-1B
Page 1 of 13
(pv01/29/2019)
Nevada Medicaid and Nevada Check Up
Mobility Assessment and Prior Authorization (PA) Request
For Mobility Devices, Wheelchair Accessories and Seating Systems
Upload this request through the Provider Web Portal.
Questions? Call: (800) 525-2395
Before completing this form, refer to the detailed instructions (FA-1B-I).
**Completion of this form does not guarantee approval or reimbursement for the items requested.**
NOTES:
SECTION I: PRIOR AUTHORIZATION (PA) INFORMATION
(This section to be completed by the Medicaid provider requesting PA.)
1. PA Request Date:
2. Assessment Date:
3. Prescription/Order Date:
4. Request Type:
Initial
Continued Services
Retrospective
Unscheduled Revision
5. For “retrospective” requests only, enter the Medicaid Eligibility Determination Date:
6. For children under age 21 only, is this request a result of, or pursuant to Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) Healthy Kids services?
Yes
No
Unknown
RECIPIENT INFORMATION (Recipient name must match Medicaid card/records.)
7. Name (last, first):
8. Recipient ID:
9a. Date of Birth:
9b. Age: ____ years ____ months
10. Sex:
Female
Male
11. Phone:
12. Address (include city, state and zip):
13. Recipient’s place of residency
Hospital
Nursing Facility
ICF / MR
Group Home
Assisted Living
Private Home
Apartment
Temporary Lodging
Other (specify):
Length of Residency:_________________________________________
14. For recipients in or being discharged from a medical facility, enter actual or anticipated discharge date:
15a. Check all that apply and provide identification numbers as applicable:
The recipient is covered by:
Medicare Part A
Medicare Part B
Medicare Number: ____________________
Other Insurance Name (if applicable):
Group ID Number: ____________________
15b. Does this recipient meet the standard Medicare criteria for the requested item(s)?
Yes
No
Not applicable
(If “No”, PA will be processed. The provider agrees to obtain a signed Advance Beneficiary Notice (ABN) for any
services Medicare does not cover due to medical necessity.)
ORDERING PHYSICIAN/PRACTITIONER INFORMATION (Must be treating physician)
16. Name:
17. NPI:
18. Address (include city, state and zip):
19. Phone:
20. Fax:
21. Contact Name:
SERVICING DME PROVIDER / SUPPLIER INFORMATION
(This section may be completed by any Medicaid provider involved in this request.)
22. Name:
23. NPI:
24. Address (include city, state and zip):
25. Phone:
26. Fax:
27. Contact Name:
Updated 10/27/2021
FA-1B
Page 1 of 13
(pv01/29/2019)
Nevada Medicaid and Nevada Check Up
Mobility Assessment and Prior Authorization (PA) Request
SECTION II: CURRENT EQUIPMENT / DEVICES
(This section must be completed by the Medicaid provider requesting PA.)
1. Identify equipment recipient currently has / uses relevant to this request. (Check all that apply.)
Manual Wheelchair
Power Wheelchair
Scooter / POV
Power Assist or Other Mobility Device
Mobility Base
Seating and Positioning Device(s)
Cane
Crutches
Walker
Geri Chair
Other: ________________________________
2. Make: _____________________________ Model: ______________________ Serial #: _______________________
Age of Equipment: ________________________ Within Manufacturer’s Warranty?
Yes
No
3. If requesting a replacement device issued less than five years ago, check the appropriate box and explain below.
N / A
Growth
Change in Condition
Weight gain ______lbs.
Weight loss______lbs.
Other
Explain:
4. Which specific MRADLs is the recipient unable to adequately complete using their current mobility devices and why?
5. Can the current equipment be modified to accommodate the recipient’s needs?
Yes
No
If yes, describe:
6. Has this equipment already been modified to accommodate the recipient’s needs?
Yes
No
If yes, describe:
EQUIPMENT/DEVICE(S) REQUESTED
7. Identify the requested equipment / device(s). (Check all that apply.)
New Mobility Device
Manual Wheelchair
Power Wheelchair
Power Operated Vehicle / Scooter
Wheelchair Accessory
Seating and Positioning Items
Growth of Current Device
Replacement Mobility Device
Modification or Changes
Other Equipment
Enter a brief description and product code for each piece of equipment being requested. Submit an unaltered complete
order form specific to the manufacturer and the model of the items being requested here.
8. Is this request for a pediatric device?
Yes
No
If no, skip the rest of this item.
Can this equipment be enlarged or reduced in size, width and depth?
Yes
No
N / A
Enter Available Seat Width Range (if applicable): ________________
Enter Available Seat Depth Range (if applicable): __________________
If this request is for a pediatric device, describe any additional growth capabilities associated with this equipment:
Updated 10/27/2021
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Nevada Medicaid and Nevada Check Up
Mobility Assessment and Prior Authorization (PA) Request
9. List the name, credentials and professional license number of the person who completed Section II.
SECTION III: CLINICAL ASSESSMENT
(This section must be completed by the ordering physician / practitioner.)
1. List pertinent diagnosis and describe conditions, symptoms or medical complaints that contributed to this request:
(Attach additional sheets if additional space is needed.)
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Nevada Medicaid and Nevada Check Up
Mobility Assessment and Prior Authorization (PA) Request
2. If primary medical condition preventing functional ambulation is related to conditions such as Congestive Heart Failure
(CHF) or Chronic Obstructive Pulmonary Disease (COPD), 1) attach the progress notes from the last six office visits
with the prescribing physician and 2) attach all pertinent documentation of severity of illness, which may include
diagnostic tests such as, but not limited to:
a. Echocardiogram report
b. Cardiolyte report
c. Cardiac catheterization report
d. Pulmonary function test
e. ABG’s and/or O2 saturation on current oxygen flow rate
Updated 10/27/2021
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Nevada Medicaid and Nevada Check Up
Mobility Assessment and Prior Authorization (PA) Request
3. If primary medical condition preventing functional ambulation is related to conditions such as Degenerative Joint
Disease, Degenerative Disc Disease or Spinal Stenosis, 1) attach all imaging reports documenting severity of illness,
2) attach the progress notes from the last six office visits with the prescribing physician 3) describe all failed
conservative treatments and include assessments, documentation and/or progress notes from those entities and 4)
provide dates of each set of treatments. Treatments may include but are not limited to:
a. PT/OT
b. Pain management
c. NSAIDS
d. Bracing and injections
e. Surgical treatments
Updated 10/27/2021
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