Form FA-60 "Mac Pricing Appeal Form" - Nevada

What Is Form FA-60?

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 February 24, 2020;
  • 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-60 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form FA-60 "Mac Pricing Appeal Form" - Nevada

Download PDF

Fill PDF online

Rate (4.8 / 5) 22 votes
Date :
MAC Pricing Appeal Form
Appeals must be submitted within 30 days or within such time period
as may be required by applicable state law, of the claim fill date.
Please complete the form and fax to 1-866-285-8652
All fields are required - Incomplete forms will not be reviewed
Provider Information:
Pharmacy/Provider Name:
Pharmacy/Provider NCPDP ID:
Pharmacy/Provider NPI:
Contact Name:
Phone Number:
Fax Number to send response:
E-mail :
Member Information:
Last Name :
First Name :
Member ID:
Middle Initial:
Rx Number :
Date of Birth :
Claim Information:
Claim Authorization Number:
Brand
Generic
BIN :
Submitted Group :
PCN:
NDC:
Claim Fill Date:
Qty
Dispensed Product Name:
Invoice Price:
Product Strength:
Drug Form:
Comments:
MUST submit invoice showing NDC of the claim being disputed with this form
FA-60
2/24/2020
Page 1 of 1
Date :
MAC Pricing Appeal Form
Appeals must be submitted within 30 days or within such time period
as may be required by applicable state law, of the claim fill date.
Please complete the form and fax to 1-866-285-8652
All fields are required - Incomplete forms will not be reviewed
Provider Information:
Pharmacy/Provider Name:
Pharmacy/Provider NCPDP ID:
Pharmacy/Provider NPI:
Contact Name:
Phone Number:
Fax Number to send response:
E-mail :
Member Information:
Last Name :
First Name :
Member ID:
Middle Initial:
Rx Number :
Date of Birth :
Claim Information:
Claim Authorization Number:
Brand
Generic
BIN :
Submitted Group :
PCN:
NDC:
Claim Fill Date:
Qty
Dispensed Product Name:
Invoice Price:
Product Strength:
Drug Form:
Comments:
MUST submit invoice showing NDC of the claim being disputed with this form
FA-60
2/24/2020
Page 1 of 1