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-71?
A: Form FA-71 is a Prior Authorization Request for Multiple Sclerosis treatment with Ampyra.
Q: What is Multiple Sclerosis?
A: Multiple Sclerosis is a chronic neurological condition that affects the central nervous system.
Q: What is Ampyra?
A: Ampyra is a medication used to improve walking in individuals with Multiple Sclerosis.
Q: What is a Prior Authorization Request?
A: A Prior Authorization Request is a process used by insurance companies to determine coverage for a specific medication or treatment.
Q: Why is a Prior Authorization Request needed?
A: A Prior Authorization Request is needed to ensure that the requested medication or treatment is medically necessary and meets the insurance company's criteria for coverage.
Q: What information is required in Form FA-71?
A: Form FA-71 typically requires information such as the patient's demographic details, medical history, diagnosis, prescribing healthcare provider, and supporting documentation.
Q: What happens after I submit Form FA-71?
A: After you submit Form FA-71, the insurance company will review the request and make a determination regarding coverage.
Q: How long does it take to get a decision on a Prior Authorization Request?
A: The time frame for a decision on a Prior Authorization Request can vary depending on the insurance company. It is best to check with your insurance provider for an estimated timeline.
Download a fillable version of Form FA-71 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.