Form FA-15 "Residential Treatment Center Prior Authorization" - Nevada

What Is Form FA-15?

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-15 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-15 "Residential Treatment Center Prior Authorization" - Nevada

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Prior Authorization Request Form
Nevada Medicaid and Nevada Check Up
Residential Treatment Center
Upload this request through the Provider Web Portal.
For questions regarding this form, call: (800) 525-2395
______ /______ /________
REQUEST DATE:
REQUEST TYPE:
Initial Review
Retrospective Authorization – Date of Eligibility Decision__________
NOTES:
I. RECIPIENT INFORMATION
Recipient Name (Last, First, MI):
Recipient Medicaid ID:
DOB:
Address:
Phone:
City:
State:
Zip Code:
Recipient’s Marital Status:
Single
Married
Separated
Divorced
Where does recipient reside?
Group Home
Parents
Relatives
Foster Care
Other:
Is the recipient currently in state custody?
Yes
No
II. RESPONSIBLE PARTY INFORMATION
Name:
Address:
Phone:
City:
State:
Zip Code:
Relationship to recipient:
Parents
Other relative
Government agency
Other:
III. ADMITTING FACILITY INFORMATION
Facility Name:
NPI:
Address:
City:
State:
Zip Code:
Phone:
Fax:
IV. ICD-10 DIAGNOSIS
Primary Code:
Disorder:
Secondary Code:
Disorder:
Tertiary Code:
Disorder:
V. CLINICAL INFORMATION
Admission Status:
Elective
Involuntary
Voluntary
Court Committed
Other:
Recipient Transferred From:
Is this request for Healthy Kids (EPSDT) services?
Yes
No
Special precautions for this recipient:
SP
Aggression
Elopement
Other:
Intervals:
q15
q30
q 1 hour
Routine
Other:
Recipient’s Current Medication(s)
Dosage
Frequency
Start Date
1.
2.
3.
4.
FA-15
Page 1 of 4
Updated 09/25/2019 (pv01/30/2019)
Prior Authorization Request Form
Nevada Medicaid and Nevada Check Up
Residential Treatment Center
Upload this request through the Provider Web Portal.
For questions regarding this form, call: (800) 525-2395
______ /______ /________
REQUEST DATE:
REQUEST TYPE:
Initial Review
Retrospective Authorization – Date of Eligibility Decision__________
NOTES:
I. RECIPIENT INFORMATION
Recipient Name (Last, First, MI):
Recipient Medicaid ID:
DOB:
Address:
Phone:
City:
State:
Zip Code:
Recipient’s Marital Status:
Single
Married
Separated
Divorced
Where does recipient reside?
Group Home
Parents
Relatives
Foster Care
Other:
Is the recipient currently in state custody?
Yes
No
II. RESPONSIBLE PARTY INFORMATION
Name:
Address:
Phone:
City:
State:
Zip Code:
Relationship to recipient:
Parents
Other relative
Government agency
Other:
III. ADMITTING FACILITY INFORMATION
Facility Name:
NPI:
Address:
City:
State:
Zip Code:
Phone:
Fax:
IV. ICD-10 DIAGNOSIS
Primary Code:
Disorder:
Secondary Code:
Disorder:
Tertiary Code:
Disorder:
V. CLINICAL INFORMATION
Admission Status:
Elective
Involuntary
Voluntary
Court Committed
Other:
Recipient Transferred From:
Is this request for Healthy Kids (EPSDT) services?
Yes
No
Special precautions for this recipient:
SP
Aggression
Elopement
Other:
Intervals:
q15
q30
q 1 hour
Routine
Other:
Recipient’s Current Medication(s)
Dosage
Frequency
Start Date
1.
2.
3.
4.
FA-15
Page 1 of 4
Updated 09/25/2019 (pv01/30/2019)
Prior Authorization Request Form
Nevada Medicaid and Nevada Check Up
Residential Treatment Center
Yes
No (If Yes, complete the next two rows.)
Does the recipient have any drug/alcohol issues?
Substances used:
Frequency/Amount of use:
Yes
No (If Yes, complete the next two rows.)
Has the recipient received drug/alcohol treatment?
Where was treatment received?
When was treatment received?
Blood Alcohol Level (if done):
Urine Drug Screen (if done):
Describe any drug/alcohol withdrawal symptoms:
What is the recipient’s current mental status?
Which symptoms/behaviors necessitate residential treatment?
Is there active involvement by family members and/or pre-admission caregivers?
Yes
No
Describe the recipient’s living environment (e.g., who lives in the home, relevant history, current support):
Have less restrictive services been documented as insufficient to meet the individual’s needs?
Yes
No
Does the recipient meet SED criteria?
Yes
No
Previous Outpatient Treatment
Provider(s):
When was treatment provided?
FA-15
Page 2 of 4
Updated 09/25/2019 (pv01/30/2019)
Prior Authorization Request Form
Nevada Medicaid and Nevada Check Up
Residential Treatment Center
Describe outcome of previous outpatient treatment.
Previous Inpatient Treatment:
Where was treatment provided?
Admit Date:
Discharge Date:
Describe outcome of previous inpatient treatment.
VI. REQUESTED DATES AND SERVICES
Requested Admission Date:
Number of Days Requested:
The recipient’s treatment plan includes:
Individual Therapy
Group Psychotherapy
Family Therapy
Does the recipient have an Individualized Education Plan (IEP)?
Yes
No
If “No,” does the treatment plan include a referral for an IEP?
Yes
No
If this is an out-of-state placement, are you prepared to produce written verification of unavailability of
appropriate in-state services?
Yes
No
What is the proposed treatment for this recipient?
Describe the recipient’s discharge plan:
FA-15
Page 3 of 4
Updated 09/25/2019 (pv01/30/2019)
Prior Authorization Request Form
Nevada Medicaid and Nevada Check Up
Residential Treatment Center
Certificate of Need
REQUESTED ADMISSION DATE: ______ /______ /________
SERVICE TYPE:
Inpatient Psychiatric
Residential Treatment Center (RTC) Initial Request
RECIPIENT INFORMATION
Recipient Name (Last, First, MI):
SSN:
Recipient ID Number:
DOB:
CASE MANAGER / REFERRING PROVIDER INFORMATION
Does the recipient have a case manager?
Yes
No
Case Manager Name:
Mental Health Center:
Phone:
Case Manager Signature:
Date:
Referring Provider Name:
Referring Provider NPI:
ADMITTING FACILITY INFORMATION
Facility Name:
NPI:
Phone:
Fax:
CERTIFICATION STATEMENTS
A physician acting within the scope of practice as defined by State law certifies the following:
1. Ambulatory care resources available in the community do not meet the treatment needs of the recipient
listed above.
2. Proper treatment of the recipient’s psychiatric condition requires inpatient or residential treatment services under
the direction of a physician.
3. The services can reasonably be expected to improve the recipient’s condition or prevent further regression so
that services will no longer be needed.
PHYSICIAN CERTIFICATION
(required)
Name:
Title:
Signature:
Date:
Additional Notes:
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-15
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Updated 09/25/2019 (pv01/30/2019)
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