Get nevada prior authorization form 2016-2024

NEVADA UNIVERSAL PRIOR AUTHORIZATION AND REFERRAL FORM Health Plan of Nevada HPN Nevada Exchange Sierra Choice Tier I HMO Tier II PPO Senior Dimensions Smart Choice/Nevada Check Up Sierra Health and Life Out of plan Primary Care Provider Name / Address / Phone Fax Tier III Sierra Spectrum Phone LV 702-242-7330 outside LV 800-288-2264 Fax LV 702838-8297 outside LV 888-633-9301 Requesting Provider Name Date of Request Member Name member number Members Address Phone HIPAA Provider Identification Member s DOB Contact Person Name Phone Fax Employer Group s Name Phone Other Insurance s Procedure/Treatment Request incl. CPT code Diagnosis incl. ICD code Number of Treatments Requested Inpatient / Outpatient Services Requested by Patient YES Service Provider / Address / Phone NO Place of Service / Facility and Address Requested Procedure Date / Start Treatment Date Area for internal health plan use only Authorization Date of Authorization Pended / Denied Reason CURRENT CLINICAL FINDINGS AND MANAGEMENT All procedures/treatment requested require clinical information may use the space also see requirements below and attach to this form. Health Plan Contact name phone Yes No All sections of this form must be completed. Pertinent Attachments Information to support the proposed diagnosis treatment/procedure i.e. current clinical findings progress reports results of laboratory testing imaging studies x-rays etc. must be submitted to prevent processing delays. On adverse determinations a reconsideration / expedited appeal may be requested* This referral/authorization is not a guarantee of payment. Payment is contingent upon eligibility benefits available at the time the service is rendered contractual terms limitations exclusions and coordination of benefits and other terms conditions set forth in the member s Evidence of Coverage Certificate of Coverage or Self Insured Employer s Plan Documents. The information contained in this form including attachments is privileged and confidential 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 the agent responsible to deliver 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* Revised 2/24/16 S4590 02/16. On adverse determinations a reconsideration / expedited appeal may be requested* This referral/authorization is not a guarantee of payment. Payment is contingent upon eligibility benefits available at the time the service is rendered contractual terms limitations exclusions and coordination of benefits and other terms conditions set forth in the member s Evidence of Coverage Certificate of Coverage or Self Insured Employer s Plan Documents. Payment is contingent upon eligibility benefits available at the time the service is rendered contractual terms limitations exclusions and coordination of benefits and other terms conditions set forth in the member s Evidence of Coverage Certificate of Coverage or Self Insured Employer s Plan Documents. The information contained in this form including attachments is privileged and confidential 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 the agent responsible to deliver 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* Revised 2/24/16 S4590 02/16. .