Form FA-96 Nevada Medicaid Hospice Extended Care Physician Review Form - Nevada

Form FA-96 or the "Nevada Medicaid Hospice Extended Care Physician Review Form" is a form issued by the Nevada Department of Health and Human Services.

The form was last revised in February 23, 2017 and is available for digital filing. Download an up-to-date Form FA-96 in PDF-format down below or look it up on the Nevada Department of Health and Human Services Forms website.

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Nevada Medicaid and Nevada Check Up
Nevada Medicaid Hospice Extended Care Physician Review Form
Purpose: Medicaid hospice benefits are reserved for terminally ill patients who have a medical prognosis to live no more
than six (6) months if the illness runs its normal course.
When an adult patient (21 years of age or older) reaches 12 months in hospice care, an independent face-to-face
physician review is required. Independent reviews are subsequently required every 12 months thereafter if the patient
continues to receive extended hospice care.
Hospice agencies should advise patients of this requirement and provide this form to take with them to each independent
review. Prior authorization requests for extended hospice care will be denied if this form is not submitted along with the
PA request or if this form indicates the patient does not continue to meet program eligibility requirements.
Instructions: Submit this form with the Hospice Prior Authorization Request (form FA-95).
SECTION I: RECIPIENT INFORMATION
(to be completed by Hospice provider)
Recipient First Name:
Recipient Last Name:
Recipient Medicaid ID:
Recipient Date of Birth:
Hospice Provider Name:
Hospice Provider NPI:
SECTION II: INDEPENDENT PHYSICIAN EVALUATION RESULTS
(to be completed by the independent
physician)
Does this recipient have a terminal illness?
Yes
No
Inconclusive
If you replied “Yes” please list the terminal diagnosis/es: (
Please note: principal diagnoses of “debility” or “adult
failure to thrive” will not be accepted as meeting the eligibility criteria for Medicaid hospice. )
Considering the normal course of the patient’s diagnosis/es, does it appear the patient’s life expectancy is six
(6) months or less if the illness runs its normal course?
Yes
No
Inconclusive
SECTION III: INDEPENDENT PHYSICIAN’S CERTIFICATION STATEMENT
I certify that I am a physician licensed in the state of Nevada and that I am not affiliated with the hospice agency
listed in Section I above. I further certify that I (or my staff) entered the evaluation results listed above and that
they are based on a face-to- face evaluation performed on _____________________(date). The conclusions
listed are unbiased and free from influence.
Physician’s Printed Name:
License #:
Physician’s Signature:
Date:
This review 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-96
Page 1 of 1
02/23/2017
Nevada Medicaid and Nevada Check Up
Nevada Medicaid Hospice Extended Care Physician Review Form
Purpose: Medicaid hospice benefits are reserved for terminally ill patients who have a medical prognosis to live no more
than six (6) months if the illness runs its normal course.
When an adult patient (21 years of age or older) reaches 12 months in hospice care, an independent face-to-face
physician review is required. Independent reviews are subsequently required every 12 months thereafter if the patient
continues to receive extended hospice care.
Hospice agencies should advise patients of this requirement and provide this form to take with them to each independent
review. Prior authorization requests for extended hospice care will be denied if this form is not submitted along with the
PA request or if this form indicates the patient does not continue to meet program eligibility requirements.
Instructions: Submit this form with the Hospice Prior Authorization Request (form FA-95).
SECTION I: RECIPIENT INFORMATION
(to be completed by Hospice provider)
Recipient First Name:
Recipient Last Name:
Recipient Medicaid ID:
Recipient Date of Birth:
Hospice Provider Name:
Hospice Provider NPI:
SECTION II: INDEPENDENT PHYSICIAN EVALUATION RESULTS
(to be completed by the independent
physician)
Does this recipient have a terminal illness?
Yes
No
Inconclusive
If you replied “Yes” please list the terminal diagnosis/es: (
Please note: principal diagnoses of “debility” or “adult
failure to thrive” will not be accepted as meeting the eligibility criteria for Medicaid hospice. )
Considering the normal course of the patient’s diagnosis/es, does it appear the patient’s life expectancy is six
(6) months or less if the illness runs its normal course?
Yes
No
Inconclusive
SECTION III: INDEPENDENT PHYSICIAN’S CERTIFICATION STATEMENT
I certify that I am a physician licensed in the state of Nevada and that I am not affiliated with the hospice agency
listed in Section I above. I further certify that I (or my staff) entered the evaluation results listed above and that
they are based on a face-to- face evaluation performed on _____________________(date). The conclusions
listed are unbiased and free from influence.
Physician’s Printed Name:
License #:
Physician’s Signature:
Date:
This review 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-96
Page 1 of 1
02/23/2017

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