MedicaidPrior AuthHigh impact
Substance Use Treatment/Outpatient Behavioral Health Authorization Request (Form FA-11D) Updated
Nevada Medicaid·NV · Psychiatry, Family Medicine, Internal Medicine +1 more·Prior Authorization
Effective date
Jul 17, 2024
We identified it
Jun 21, 2026
Summary
Nevada Medicaid has updated the Substance Use Treatment/Outpatient Behavioral Health Authorization Request form (FA-11D) to require prescriber/requester signatures. The old form version must be discontinued immediately and replaced with the new form dated 07/02/2024.
Action Required
Immediately: Discontinue use of old FA-11D forms and switch to the new form dated 07/02/2024. Ensure all prescribers and requesters sign the form (wet or electronic signatures accepted). From July 17 through August 31, 2024: Expect pended requests if old forms are used - resubmit within 5 days using new form. Starting September 1, 2024: All requests will be denied if new form is not used or required signatures are missing.