This is a legal form that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.
Q: What is Form FA-86?
A: Form FA-86 is a Prior Authorization Request form.
Q: What is Amevive (Alefacept)?
A: Amevive (Alefacept) is a medication.
Q: What is the purpose of this form?
A: The purpose of this form is to request prior authorization for Amevive (Alefacept) in Nevada.
Q: How do I obtain this form?
A: You can obtain this form by contacting your healthcare provider or insurance company.
Q: What do I need to include in this form?
A: You need to include information such as patient details, healthcare provider information, diagnosis, and medical justification for the requested medication.
Q: What happens after submitting this form?
A: After submitting this form, your insurance company will review the request and determine if prior authorization will be granted.
Q: Are there any specific requirements for this form in Nevada?
A: It is recommended to follow the specific instructions and requirements provided by the Nevada Medicaid Program or your insurance company.
Q: Can I appeal if my request is denied?
A: Yes, you have the right to appeal if your request for prior authorization is denied. Contact your insurance company for more information on the appeals process.
Q: Is there a deadline to submit this form?
A: There may be a deadline to submit this form, so it's important to check with your healthcare provider or insurance company for any specific timelines.
Download a fillable version of Form FA-86 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.