Form FA-90 "Formal Claim Appeal Request" - Nevada

What Is Form FA-90?

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 April 10, 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-90 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-90 "Formal Claim Appeal Request" - Nevada

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Nevada Medicaid and Nevada Check Up
Formal Claim Appeal Request
Purpose: Use this form to request a formal claim appeal. Do not use this form to submit adjustments/voids, to
make corrections to claims or to resubmit a denied claim.
Claim appeals must be submitted via the Provider Web Portal (PWP). To submit a claim appeal, log on to the PWP
and navigate to Secure Correspondence. For detailed information regarding how to use Secure Correspondence
for claim appeals, refer to Electronic Verification System (EVS) User Manual Chapter 1 (Getting Started) and
Chapter 3 (Claims) on the EVS User Manual webpage at www.medicaid.nv.gov.
For questions regarding this form, call (877) 638-3472
DATE: ________/________/_________
PROVIDER INFORMATION
Provider Name:
Provider NPI/API:
Name of person to be contacted regarding the appeal:
Contact person phone number:
CLAIM INFORMATION
Internal control number (ICN) (13 digits):
REASON FOR THE CLAIM APPEAL
(be specific)
ATTACHMENTS
Please check the box if you are including attachments with this Formal Claim Appeal Request:
Documentation to support the appeal request, e.g., physician’s notes, medical records, etc.
FA-90
Page 1 of 1
04/10/2019
Nevada Medicaid and Nevada Check Up
Formal Claim Appeal Request
Purpose: Use this form to request a formal claim appeal. Do not use this form to submit adjustments/voids, to
make corrections to claims or to resubmit a denied claim.
Claim appeals must be submitted via the Provider Web Portal (PWP). To submit a claim appeal, log on to the PWP
and navigate to Secure Correspondence. For detailed information regarding how to use Secure Correspondence
for claim appeals, refer to Electronic Verification System (EVS) User Manual Chapter 1 (Getting Started) and
Chapter 3 (Claims) on the EVS User Manual webpage at www.medicaid.nv.gov.
For questions regarding this form, call (877) 638-3472
DATE: ________/________/_________
PROVIDER INFORMATION
Provider Name:
Provider NPI/API:
Name of person to be contacted regarding the appeal:
Contact person phone number:
CLAIM INFORMATION
Internal control number (ICN) (13 digits):
REASON FOR THE CLAIM APPEAL
(be specific)
ATTACHMENTS
Please check the box if you are including attachments with this Formal Claim Appeal Request:
Documentation to support the appeal request, e.g., physician’s notes, medical records, etc.
FA-90
Page 1 of 1
04/10/2019