The Nevada Medicaid FA-11 form is the Behavioral Health Outpatient or Rehabilitative Authorization Request that providers use to seek prior authorization for outpatient mental health, substance use disorder, and rehabilitative services covered under Nevada Medicaid and Nevada Check Up.1Nevada Medicaid. Behavioral Health Outpatient or Rehabilitative Authorization Request – FA-11 It is completed by the requesting provider, submitted electronically through the Provider Web Portal, and must be signed by a licensed professional before Nevada Medicaid will review it. Applied Behavior Analysis services use a different form, the FA-11E.2Nevada Medicaid and Nevada Check Up. Applied Behavior Analysis (ABA) Authorization Request – FA-11E
When the FA-11 Is Required
The form is used when a recipient needs behavioral health services that exceed the baseline limits in the Nevada Medicaid Services Manual, or when a specific service always requires authorization. Under the Nevada State Plan, prior authorization applies to mental health therapy and substance use counseling once limits are hit, to all neuro-cognitive and psychological testing, to day treatment that exceeds limits, to adult peer support beyond 52 hours (208 units) per year, to psychiatric diagnostic evaluations beyond two per year for adults or four per year for youth, and to intensive crisis stabilization and crisis intervention beyond standard limits.3Medicaid.gov. Nevada State Plan Amendment 22-0005
The FA-11 is not the right form for durable medical equipment, surgical procedures, non-emergency transportation, or ABA services. Those requests move through different authorization pathways.
What to Gather Before You Open the Form
Collecting these items up front cuts down on back-and-forth and avoids denials for incomplete information:
- The recipient’s 11-digit Medicaid ID, from the front of their Medicaid card.4Nevada Medicaid. Provider Web Portal User Manual Chapter Two – Eligibility Benefit Verification
- Up to three ICD-10 diagnosis codes (primary, secondary, tertiary). For children under three assessed with DC:0-3, cross-walk to the ICD-10 equivalent.
- HCPCS or CPT procedure codes and any applicable modifiers for the services you are requesting.
- A current medication list with dosages, frequencies, and any changes since the last report.
- A full treatment history with dates for every prior level of behavioral health care.
- The treatment plan: long- and short-term goals, strengths, psychosocial supports, and progress or regression during the last authorized period.
- A discharge plan with an estimated discharge date.
Filling Out the Form Section by Section
The top of the form asks for the date and the type of request: initial, concurrent, unscheduled revision, or retrospective. Retrospective requests also require the eligibility decision date.1Nevada Medicaid. Behavioral Health Outpatient or Rehabilitative Authorization Request – FA-11
Section I: Recipient Information
Enter the recipient’s name, date of birth, 11-digit Medicaid ID, and age. Indicate whether the recipient is in specialized foster care and whether they are in state or county custody. If custody applies, add the point of contact and the date custody began. Any mismatch against the state’s eligibility files stalls the request before clinical review.
Section II: ICD-10 Diagnosis
List up to three ICD-10 codes with their disorder names, primary first. The primary diagnosis should directly support the clinical case for the services you are requesting. For DC:0-3 assessments, enter the ICD-10 cross-walk code rather than the DC:0-3 code.
Section III: Current Medications
List every behavioral-health-related medication the recipient is currently taking, with dosage and frequency. Flag changes since the last report. Reviewers use this to judge whether medication alone is adequate or whether the requested service fills a gap.
Section IV: Current Symptoms and Significant Life Events
Describe, in clinical narrative form, the symptoms and life events tied to the primary diagnosis and explain why treatment is needed now. The form prompts for family dynamics, developmental history, medical issues, substance use history, and legal history. Vague descriptions here are one of the main reasons requests get denied.
Section V: Treatment Plan Rationale and Progress
For each identified problem or behavior, document long- and short-term goals, the recipient’s strengths and psychosocial supports, and whether they progressed or regressed during the last authorized period. On concurrent authorizations, this section carries the weight of the request: the reviewer needs to see that current treatment is working and that ending it would set the recipient back.
Section VI: Treatment History
Check yes or no, with dates, for every prior level of care the recipient has received:
- Outpatient therapy
- Outpatient substance abuse treatment
- Applied Behavior Analysis
- Intensive outpatient program
- Partial hospitalization program
- Inpatient psychiatry
- Outpatient psychiatry and medication management
- Psychiatric residential treatment facility
- Rehabilitative mental health services (basic skills training, psychosocial rehabilitation)
Use the additional treatment history field at the bottom for anything that does not fit a listed category.
Section VII: Discharge Plan
Provide an estimated discharge date and describe how the recipient will transition out of the service. Even for chronic conditions, reviewers want to see a defined trajectory rather than an open-ended request.
Section VIII: Requested Services and Unit Calculation
For each service, enter the procedure code, modifier, start and end dates, units per day, and days per week. The form uses a fixed formula:
Units per day × Days per week × Total weeks in the date span = Total units1Nevada Medicaid. Behavioral Health Outpatient or Rehabilitative Authorization Request – FA-11
Two units per day, three days per week, over 12 weeks works out to 72 units. Check the arithmetic and make sure the date span actually covers the number of weeks you used. Unit-calculation errors are a common cause of partial approvals or denials.
Who Signs the Form
The attestation at the bottom is signed by a Licensed Professional or Qualified Mental Health Professional (QMHP), who prints their name, lists their credentials, and dates the form. When the request is only for peer support services, a Certified Peer Support Specialist Supervisor or Clinical Supervisor signs the second attestation block instead of the first.1Nevada Medicaid. Behavioral Health Outpatient or Rehabilitative Authorization Request – FA-11 The signer is the point of contact for the entire authorization and is responsible for sharing information about the request with other parties involved.
How to Submit the Form
Upload the completed FA-11 through the Nevada Medicaid Provider Web Portal. Since January 2019, all prior authorizations must be submitted electronically; paper is no longer accepted.5Nevada Medicaid. Prior Authorization Procedure and Diagnosis Reference Lists The portal is reached through the Provider Web Portal link on the Nevada Medicaid website, and upload instructions are in Chapter 8 of the Provider Web Portal User Manual.6Nevada Medicaid Provider Portal. Providers Forms For questions about submission or status, call (800) 525-2395, the number printed on the form.
What Causes Denials
Nevada Medicaid’s quarterly denial reports show the same issues coming up repeatedly:
- Incomplete or vague clinical documentation in Sections IV and V.
- Submission outside Nevada Medicaid’s timely filing rules, which triggers an automatic denial for late notification.
- Unit calculations that do not match the requested date span.
- Recipient name, date of birth, or Medicaid ID that does not match the state’s eligibility files.
An approved authorization is not a guarantee of payment. Payment still depends on the recipient’s eligibility at the time of service, available benefits, coordination of benefits, and the other terms of the Medicaid program.1Nevada Medicaid. Behavioral Health Outpatient or Rehabilitative Authorization Request – FA-11
When to Expect a Decision
Timelines depend on how the recipient’s Medicaid is administered. For managed care enrollees, federal rules apply. Starting with rating periods on or after January 1, 2026, MCOs must issue standard decisions within seven calendar days, down from 14, with up to 14 additional days available when the enrollee or provider requests the extension or when the MCO needs more information and can justify how the delay benefits the enrollee. Expedited decisions, used when waiting could seriously threaten the enrollee’s life, health, or ability to function, must be issued within 72 hours, with the same 14-day extension rules.7eCFR. 42 CFR 438.210 – Coverage and Authorization of Services
For fee-for-service recipients, there is no federally mandated decision deadline. Nevada sets its own timeframes, so check the current Medicaid Services Manual chapter for the specific service.
If the Request Is Denied
Both the provider and the Medicaid member get notice of a denial. A provider appeal must be submitted to Nevada Medicaid within 30 calendar days of the notice date. If the appeal is denied, the Notice of Decision will explain how to request a fair hearing through the Division of Health Care Financing and Policy. Fair hearing requests must be received within 90 days of the appeal denial notice date, with the day after the notice counted as day one.8Nevada Medicaid. Claim Appeals, Adjustments and Voids
Read the denial reason before choosing a path. When the problem is missing documentation rather than a clinical disagreement, a fresh, complete submission is often faster than an appeal.