The Universal Referral Nevada form is a critical document used to facilitate prior authorization and referrals for medical services within various health plans in Nevada. This form ensures that all necessary information is collected from the requesting provider, allowing for efficient processing and communication between healthcare providers and insurance companies. For those in need of medical services, completing this form accurately is essential; begin by clicking the button below.
NEVADA UNIVERSAL
PRIOR AUTHORIZATION AND REFERRAL FORM
Health Plan of Nevada (HPN):
Primary Care Provider Name / Address / Phone & Fax #:
Nevada Exchange:
Tier I (HMO)
Tier II (PPO)
Tier III
Sierra Choice:
Senior Dimensions:
Smart Choice/Nevada Check Up:
Sierra Health and Life:
Out of plan
Sierra Spectrum:
Phone: (LV) 702-242-7330 (outside LV) 800-288-2264
Requesting Provider Name:
Fax #: (LV) 702838-8297 (outside LV) 888-633-9301
Date of Request:
Member Name & member number:
Requesting Provider’s Address & Phone #:
Requesting Provider’s Fax #:
Members Address & Phone #:
Requesting Provider’s Tax ID #:
HIPAA Provider Identification #:
Member’s DOB:
Contact Person (Name, Phone & Fax # :)
Employer Group’s Name & Phone #:
Requesting Provider’s Signature or Stamped Signature:
Other Insurance(s):
Diagnosis (incl. ICD code):
Procedure/Treatment Request (incl. CPT code):
Number of Treatments Requested: ______________
Inpatient / Outpatient:
Services Requested by Patient: YES NO
Service Provider / Address / Phone #:
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
use the space – also see requirements below and attach to this form.
All procedures/treatment requested require
clinical information (may
Health Plan Contact name & phone #:
Yes
No
Authorization Number:
*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.
* All Sections of this form must be completed.
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)
Filling out the Universal Referral Nevada form is a straightforward process that requires attention to detail. By ensuring all sections are completed accurately, you can help facilitate the necessary approvals for patient care. Below are the steps to guide you through the completion of the form.
Once the form is filled out, it should be submitted to the appropriate health plan for review. Ensure that all necessary documentation is included to support the request, as this will aid in a smoother approval process.
Facts About Nevada - This form aims to promote proactive maintenance planning and funding within associations.
The process of creating a sound plan for your estate includes understanding the importance of a well-drafted Last Will and Testament document, which guides how your assets will be handled and distributed according to your wishes.
State of Nevada Declaration of Value Form - Reviewing state laws related to property transfers can enhance understanding of the form.
What is the Universal Referral Nevada form?
The Universal Referral Nevada form is a document used by healthcare providers in Nevada to request prior authorization for services or referrals for patients. It is essential for ensuring that the necessary approvals are in place before treatment begins.
Who needs to fill out the Universal Referral Nevada form?
The form must be completed by the requesting provider, typically a primary care physician or specialist, who is seeking authorization for a patient’s treatment or referral to another provider.
What information is required on the form?
Key information includes the requesting provider's name and contact details, patient details (name, member number, date of birth), diagnosis with ICD codes, and the specific procedure or treatment requested with CPT codes. All sections of the form must be filled out completely to avoid delays.
How do I submit the Universal Referral Nevada form?
The completed form can be submitted via fax to the appropriate contact number provided on the form. Ensure all attachments and clinical information are included to support the request.
What happens after I submit the form?
After submission, the health plan will review the request. You will receive an authorization number if approved, or a notice if the request is pended or denied, along with the reason for the decision.
What should I do if my request is denied?
If your request is denied, you can request a reconsideration or expedited appeal. Be sure to gather any additional information that may support your case and follow the appeals process outlined by the health plan.
Is approval guaranteed once I submit the form?
No, submission of the form does not guarantee payment. Approval is contingent upon eligibility, benefits available at the time of service, and other terms outlined in the member’s coverage documents.
What types of services require this form?
This form is typically required for services that are not covered under routine care, such as specialized treatments, certain diagnostic tests, or referrals to specialists.
What are the consequences of incomplete forms?
Incomplete forms can lead to processing delays or outright denials. It is crucial to fill out all sections accurately and provide any necessary clinical documentation to support the request.
Is the information on the form confidential?
Yes, the information contained in the form is considered privileged and confidential. It should only be shared with the intended recipients and must be protected from unauthorized access.
Leaving sections blank. Every part of the form must be filled out completely. Missing information can lead to processing delays.
Not including the correct provider signatures. Ensure that the requesting provider's signature or stamped signature is present.
Failing to attach necessary clinical documentation. Attach all relevant clinical findings, lab results, and imaging studies to support the request.
Incorrectly filling out diagnosis and procedure codes. Double-check that ICD and CPT codes are accurate and correspond to the treatment requested.
Omitting the member's date of birth. This information is crucial for identification and processing.
Not providing a contact person. Include a name and phone number for any follow-up questions regarding the request.
Neglecting to specify the number of treatments requested. Clearly indicate how many treatments are necessary for the patient.
Ignoring the importance of timely submission. Submit the form as soon as possible to avoid delays in authorization.
When utilizing the Universal Referral Nevada form, several other documents are often required to ensure a smooth and efficient process. Each of these forms plays a crucial role in providing necessary information and facilitating communication between healthcare providers and insurance companies. Below is a list of commonly used documents that accompany the referral form.
By ensuring that these documents are completed and submitted alongside the Universal Referral Nevada form, healthcare providers can significantly reduce the likelihood of delays in processing and improve the chances of obtaining timely authorizations for patient care. It is essential to stay organized and proactive in gathering all necessary information to facilitate a smooth referral process.