Form FA-69 Prior Authorization Request - Adhd Treatment for Recipients Under Age 18 - Nevada

Form FA-69 is a Nevada Department of Health and Human Services form also known as the "Prior Authorization Request - Adhd Treatment For Recipients Under Age 18". The latest edition of the form was released in May 11, 2017 and is available for digital filing.

Download a PDF version of the Form FA-69 down below or find it on Nevada Department of Health and Human Services Forms website.

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Prior Authorization Request
Nevada Medicaid – OptumRx
ADHD Treatment for Recipients Under Age 18
Submit request to: Fax: 855-455-3303
Purpose: For a prescribing physician to request prior authorization for agents used for the treatment of attention deficit
hyper-activity disorder (ADHD) for a recipient under age 18.
Questions: If you have questions, call the OptumRx Call Center for Nevada Medicaid at 855-455-3311
DATE OF REQUEST:
RECIPIENT INFORMATION
Last Name, First Name, Middle Initial:
Date of Birth:
Recipient ID:
Gender:
Male
Female
Phone:
PRESCRIBING PROVIDER INFORMATION
Name:
NPI:
Fax (required):
Phone:
Person to contact regarding this request:
DIAGNOSIS AND REQUESTED DRUG
Applicable ICD-10 code and diagnosis or symptom/side effect (REQUIRED):
Name:
Strength:
Generic substitution not permitted
Dosage:
Duration:
COVERAGE CRITERIA
All of the following criteria must be met and documented in the recipient’s medical record.
Check the applicable boxes to indicate each item as true for the recipient:
The decision to medicate for ADD or ADHD and any comorbidity is based on problems that are persistent and
sufficiently severe to cause functional impairment at school, home, work and/or with peers, and
Other treatable causes have been ruled out, and
Initial evaluation has been done by the treating physician documenting the developmental history, physical exam,
medical history or neurological primary diagnosis and exam within the past 12 months, or more recently, if the
clinical condition has changed, and
There is documentation in the recipient’s medical record containing school information, standardized teachers rating
scales testing reports such as TOVA, achievement test, neuropsychological testing if indicated, speech and
language evaluation, and
There is documentation in the recipient’s medical record containing the symptoms of ADD or ADHD as given by the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); presence or absence-child behavior checklist; the
development and context of symptoms and their resulting impairment with family, peers, and in school; history of
psychiatric, psychological pediatric, or neurological treatment for ADD or ADHD; or that the member has DSM-IV
symptoms of a possible alternate or comorbid psychiatric diagnosis, and
There is documentation in the recipient’s medical record assessing a family history of ADD and ADHD, tic disorder,
substance abuse disorder, conduct disorder, personality disorder and other anxiety disorders, past or present family
stressors, crises, or any abuse or neglect.
The recipient will be using only one long-acting agent at a time for the treatment of ADD or ADHD.
Additional clinical information (required for non-preferred agents only):
The recipient has an allergy, history of unacceptable/toxic side effects, drug-drug interaction or contraindication to all
preferred agents in the same therapeutic class. Document:___________________________________
The recipient has experienced a therapeutic failure with two preferred agents in the same therapeutic class.
Document:_________________________________________________________________________
The non-preferred drug is being requested for a unique indication that is supported by peer-reviewed literature or
FDA-approved indication that is unique to the requested drug (document diagnosis above).
PROVIDER CERTIFICATION –
Prescriber’s signature and date required.
I hereby certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by Nevada Medicaid.
Prescriber’s Signature:
Date:
This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms,
limitations, exclusions, coordination of benefits and other terms and conditions set forth by the benefit program. The information on this form
and on accompanying attachments is privileged and confidential and is only for the use of the individual or entities named on this form. If the
reader of this form is not the intended recipient or the employee or agent responsible to deliver it to the intended recipient, the reader is
hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If this communication is received in
error, the reader shall notify sender immediately and destroy all information received.
FA-69
05/11/2017 pv11/19/2013
Page 1 of 1
Prior Authorization Request
Nevada Medicaid – OptumRx
ADHD Treatment for Recipients Under Age 18
Submit request to: Fax: 855-455-3303
Purpose: For a prescribing physician to request prior authorization for agents used for the treatment of attention deficit
hyper-activity disorder (ADHD) for a recipient under age 18.
Questions: If you have questions, call the OptumRx Call Center for Nevada Medicaid at 855-455-3311
DATE OF REQUEST:
RECIPIENT INFORMATION
Last Name, First Name, Middle Initial:
Date of Birth:
Recipient ID:
Gender:
Male
Female
Phone:
PRESCRIBING PROVIDER INFORMATION
Name:
NPI:
Fax (required):
Phone:
Person to contact regarding this request:
DIAGNOSIS AND REQUESTED DRUG
Applicable ICD-10 code and diagnosis or symptom/side effect (REQUIRED):
Name:
Strength:
Generic substitution not permitted
Dosage:
Duration:
COVERAGE CRITERIA
All of the following criteria must be met and documented in the recipient’s medical record.
Check the applicable boxes to indicate each item as true for the recipient:
The decision to medicate for ADD or ADHD and any comorbidity is based on problems that are persistent and
sufficiently severe to cause functional impairment at school, home, work and/or with peers, and
Other treatable causes have been ruled out, and
Initial evaluation has been done by the treating physician documenting the developmental history, physical exam,
medical history or neurological primary diagnosis and exam within the past 12 months, or more recently, if the
clinical condition has changed, and
There is documentation in the recipient’s medical record containing school information, standardized teachers rating
scales testing reports such as TOVA, achievement test, neuropsychological testing if indicated, speech and
language evaluation, and
There is documentation in the recipient’s medical record containing the symptoms of ADD or ADHD as given by the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); presence or absence-child behavior checklist; the
development and context of symptoms and their resulting impairment with family, peers, and in school; history of
psychiatric, psychological pediatric, or neurological treatment for ADD or ADHD; or that the member has DSM-IV
symptoms of a possible alternate or comorbid psychiatric diagnosis, and
There is documentation in the recipient’s medical record assessing a family history of ADD and ADHD, tic disorder,
substance abuse disorder, conduct disorder, personality disorder and other anxiety disorders, past or present family
stressors, crises, or any abuse or neglect.
The recipient will be using only one long-acting agent at a time for the treatment of ADD or ADHD.
Additional clinical information (required for non-preferred agents only):
The recipient has an allergy, history of unacceptable/toxic side effects, drug-drug interaction or contraindication to all
preferred agents in the same therapeutic class. Document:___________________________________
The recipient has experienced a therapeutic failure with two preferred agents in the same therapeutic class.
Document:_________________________________________________________________________
The non-preferred drug is being requested for a unique indication that is supported by peer-reviewed literature or
FDA-approved indication that is unique to the requested drug (document diagnosis above).
PROVIDER CERTIFICATION –
Prescriber’s signature and date required.
I hereby certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by Nevada Medicaid.
Prescriber’s Signature:
Date:
This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms,
limitations, exclusions, coordination of benefits and other terms and conditions set forth by the benefit program. The information on this form
and on accompanying attachments is privileged and confidential and is only for the use of the individual or entities named on this form. If the
reader of this form is not the intended recipient or the employee or agent responsible to deliver it to the intended recipient, the reader is
hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If this communication is received in
error, the reader shall notify sender immediately and destroy all information received.
FA-69
05/11/2017 pv11/19/2013
Page 1 of 1

Download Form FA-69 Prior Authorization Request - Adhd Treatment for Recipients Under Age 18 - Nevada

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