MedicaidPrior AuthHigh impact
Attention Provider Type 93 (Substance Use Treatment): Substance Use Treatment/Outpatient Behavioral Health Authorization Request (Form FA-11D) Updated
Nevada Medicaid·NV · Psychiatry·Prior Authorization
Effective date
Feb 4, 2025
We identified it
Jun 21, 2026
Summary
Nevada Medicaid updated the Substance Use Treatment/Outpatient Behavioral Health Authorization Request form (FA-11D) requiring additional information including release dates, admission/discharge dates, and facility arrival details. Providers must use the new form immediately or face denials starting March 1, 2025.
Action Required
Immediately: Download and begin using the updated Form FA-11D from Nevada Medicaid website for all substance use treatment and outpatient behavioral health prior authorization requests. Ensure staff complete new required fields: release date from state custody, admission date, discharge date, origin location, and arrival method. By March 1, 2025: Must use new form only - old form submissions will be denied after this date.