Blank Universal Referral Nevada PDF Template

The Universal Referral Nevada form is a crucial document used to request prior authorization and referrals for medical services within the Health Plan of Nevada. This form streamlines the process for healthcare providers, ensuring that all necessary information is collected to facilitate timely patient care. To get started, fill out the form by clicking the button below.

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Blank Universal Referral Nevada PDF Template

Structure

The Universal Referral Nevada form is an essential document used in the healthcare system to streamline the process of obtaining prior authorization and referrals for medical services. It is designed for use by various health plans, including Health Plan of Nevada, and covers multiple tiers such as HMO and PPO options. This form requires detailed information from both the requesting provider and the patient, including names, contact details, and medical history. Key sections of the form include the diagnosis, procedure or treatment requested, and the number of treatments needed, along with corresponding codes for accurate processing. Additionally, the form emphasizes the importance of attaching relevant clinical information to support the request, which helps prevent delays in authorization. It is crucial to note that completing all sections of the form is mandatory, as incomplete submissions can lead to processing issues. The form also contains a confidentiality notice, underscoring the importance of protecting patient information. Understanding the components and requirements of the Universal Referral Nevada form can significantly enhance the efficiency of healthcare services for patients and providers alike.

Universal Referral Nevada Sample

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

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.

**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)

Click for Universal Referral Nevada PDF

File Attributes

Fact Name	Fact Details
Form Title	Nevada Universal Prior Authorization and Referral Form
Health Plans Covered	Includes Health Plan of Nevada (HPN), Nevada Exchange, Sierra Health and Life, and others.
Required Information	All sections must be completed, including patient details, provider information, and treatment requests.
Governing Law	Subject to Nevada state laws regarding health insurance and patient confidentiality.
Authorization Status	Indicates whether the request is authorized, pended, or denied, along with the reason for denial.
Confidentiality Notice	The information is confidential and intended only for the named recipients. Unauthorized use is prohibited.

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