Form FA-11 "Behavioral Health Outpatient or Rehabilitative Authorization Request" - Nevada

What Is Form FA-11?

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.

Form Details:

  • Released on September 25, 2019;
  • 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-11 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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Download Form FA-11 "Behavioral Health Outpatient or Rehabilitative Authorization Request" - Nevada

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Nevada Medicaid and Nevada Check Up
Behavioral Health Outpatient or Rehabilitative Authorization Request
Upload this request through the Provider Web Portal. Questions? Call: (800) 525-2395
This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, benefits available at the time the
service is rendered, contractual terms, limitations, exclusions, coordination of benefits and other terms and conditions set forth by the
benefit program. The information contained in this form, including 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 has been received in error, the reader shall notify sender immediately and
shall destroy all information received.
REQUEST TYPE:
Initial Prior Authorization
Concurrent Authorization
Unscheduled Revision
Retrospective Authorization – Date of Eligibility Decision:____________________________
NOTES:
SECTION I. RECIPIENT
Name:
DOB:
Recipient Medicaid ID:
Age:
Specialized Foster Care:
Yes
No
Is the recipient in State/County custody?
Yes
No
State/County Point of Contact:
Date recipient went into State/County custody:
SECTION II. ICD-10 DIAGNOSIS
(If using DC:0-3, use the appropriate crosswalk and enter the appropriate ICD-10 diagnosis code and disorder)
Primary Code:
Disorder:
Secondary Code:
Disorder:
Tertiary Code:
Disorder:
SECTION III. ASSESSMENT SCORE
CASII
Score:
Level:
Date:
LOCUS
Score:
Level:
Date:
ECSII or Other Assessment (specify):
Score:
Level:
Date:
SECTION IV. CURRENT MEDICATION(S)
Current Medications (indicate changes since last report)
Dosage
Frequency
1.
2.
3.
4.
5.
6.
FA-11
Page 1 of 4
Updated 09/25/2019 (pv04/25/2019)
Nevada Medicaid and Nevada Check Up
Behavioral Health Outpatient or Rehabilitative Authorization Request
Upload this request through the Provider Web Portal. Questions? Call: (800) 525-2395
This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, benefits available at the time the
service is rendered, contractual terms, limitations, exclusions, coordination of benefits and other terms and conditions set forth by the
benefit program. The information contained in this form, including 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 has been received in error, the reader shall notify sender immediately and
shall destroy all information received.
REQUEST TYPE:
Initial Prior Authorization
Concurrent Authorization
Unscheduled Revision
Retrospective Authorization – Date of Eligibility Decision:____________________________
NOTES:
SECTION I. RECIPIENT
Name:
DOB:
Recipient Medicaid ID:
Age:
Specialized Foster Care:
Yes
No
Is the recipient in State/County custody?
Yes
No
State/County Point of Contact:
Date recipient went into State/County custody:
SECTION II. ICD-10 DIAGNOSIS
(If using DC:0-3, use the appropriate crosswalk and enter the appropriate ICD-10 diagnosis code and disorder)
Primary Code:
Disorder:
Secondary Code:
Disorder:
Tertiary Code:
Disorder:
SECTION III. ASSESSMENT SCORE
CASII
Score:
Level:
Date:
LOCUS
Score:
Level:
Date:
ECSII or Other Assessment (specify):
Score:
Level:
Date:
SECTION IV. CURRENT MEDICATION(S)
Current Medications (indicate changes since last report)
Dosage
Frequency
1.
2.
3.
4.
5.
6.
FA-11
Page 1 of 4
Updated 09/25/2019 (pv04/25/2019)
Nevada Medicaid and Nevada Check Up
Behavioral Health Outpatient or Rehabilitative Authorization Request
SECTION V. CURRENT SYMPTOMS AND SIGNIFICANT LIFE EVENTS
(List symptoms and/or
significant life events that relate to the recipient’s Axis I diagnosis and/or that brought the recipient to treatment, e.g.,
pertinent family information, developmental history, medical issues, sexual history, substance abuse and legal history.)
SECTION VI. TREATMENT PLAN AND RATIONALE AND PROGRESS SINCE LAST REVIEW
(Identify for each problem/behavior, long and short term goals, strengths, psychosocial supports and progress or
regression during the last authorized period.)
FA-11
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Updated 09/25/2019 (pv04/25/2019)
Nevada Medicaid and Nevada Check Up
Behavioral Health Outpatient or Rehabilitative Authorization Request
SECTION VII. PATIENT’S TREATMENT HISTORY, INCLUDING ALL LEVELS OF KNOWN CARE
Outpatient Therapy
Yes
No
Dates:
Outpatient Substance abuse
Yes
No
Dates:
Applied Behavior Analysis (ABA)
Yes
No
Dates:
Intensive Outpatient Program (IOP)
Yes
No
Dates:
Partial Hospitalization Program (PHP)
Yes
No
Dates:
Inpatient Psychiatry
Yes
No
Dates:
Outpatient Psychiatry/Medication Management
Yes
No
Dates:
Residential Treatment Center
Yes
No
Dates:
Previous Rehabilitative Mental Health (RMH)
Services (Basic Skills Training, Psychosocial
Yes
No
Dates:
Rehabilitation)
Additional Treatment History (for QMHP use, if needed):
SECTION VIII. DISCHARGE PLAN AND ESTIMATED DISCHARGE DATE
FA-11
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Updated 09/25/2019 (pv04/25/2019)
Nevada Medicaid and Nevada Check Up Behavioral Health Outpatient or Rehabilitative Authorization Request
SECTION IX. REQUESTED TREATMENT
The requester will be deemed the point of contact for this authorization request and is responsible for
.
dissemination of all information regarding this request
"Units per day" multiplied by "Days per Week" multiplied by the total number of weeks in the entire date span equals “Total Units.”
Start Date
Modifier
Days per Week
Code
Units per Day
Total Units
and End Date
1
2
3
4
5
6
Coordinating QMHP Attestation
I attest that the above information in this form is accurate.
Coordinating QMHP Signature:___________________________________________________
Licensed Credential(s):______________________________
Print Name:__________________________________________________________________
Date:____________________________________________
Clinical Supervisor Attestation (The Clinical Supervisor signature is also required if the QMHP is an intern/assistant or acting under the direction of a Clinical
Supervisor.)
I assume professional responsibility for the mental and/or behavioral health services requested per MSM 403.2A.2.
Clinical Supervisor Signature:____________________________________________________
Licensed Credential(s):______________________________
Print Name:__________________________________________________________________
Date:____________________________________________
FA-11
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