Nevada NV

Nevada Medicaid (DHCFP, now under the Nevada Health Authority/NVHA umbrella) publishes PA criteria PRIMARILY through the Medicaid Services Manual (MSM): ~45 numbered service chapters (100 Program, 200 Hospital, 300 Radiology, 600 Physician, 1200 Prescribed Drugs, 1300 DME, 1700 Therapy, etc.), each a landing page hosting a living, dated 'Current - Effective <date>' PDF plus full version history. PA requirements are embedded per-service WITHIN each chapter PDF (no single master PA-code list document). The Gainwell-operated fiscal-agent portal (medicaid.nv.gov) supplies the OPERATIONAL PA layer: a public library of numbered FA-* PA request forms keyed by service axis (FA-1 DME, FA-6 outpatient med/surg, FA-8 inpatient med/surg, FA-11 BH outpatient, FA-12 inpatient MH, FA-95 hospice, FA-24 PCS, FA-29B reconsideration) plus a login-gated 'Authorization Criteria' tool and portal PA submission. Managed care: 4 statewide MCOs (Anthem BCBS, Health Plan of Nevada/UHC, Molina, SilverSummit/Centene) own urban PA; rural + special pops stay FFS through DHCFP. Pharmacy is per-MCO PBM with FFS PDL. IMPORTANT: the pinned dhcfp.nv.gov URLs (pa_index, pharmacy, provider_manual) are all DEAD — the site was re-platformed; dhcfp.nv.gov/* now 301s to www.nevadamedicaid.nv.gov. MSM lives at /resources/medicaid-services-manual/; legacy /Resources/AdminSupport/Manuals/MSM/* paths still resolve. Gathered: 6 current MSM chapters (200/300/600/1200/1300/1700) + MSM Complete Manual + 5 representative FA-* PA forms, ingested to Corsair.

Last award: 2025-02-12 (notice of intent to award; final contracts executed 2025). Next due: approximately 2030 (5 years from 2026-01-01); option years TBD. Contracts extended through: 2025-12-31 (2021 contracts; redistribution 2026-01-01).

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

# NV — learned PA profile (local Qwen synthesis, 2026-05-28) Synth note: map=qwen2.5:7b / reduce=qwen2.5-coder:32b, 13 docs. See [[state_shape_NV]]. Correction pass: WISeR is not applicable to NV — WISeR ("Wasteful and Inappropriate Service Reduction") is a CMS Medicare PA model limited to AZ/NJ/OH/OK/TX/WA; NV does not participate. The model's "WISeR pilot status unspecified" line was a template artifact, corrected below. ## 1. How NV requires PA Nevada's Medicaid program requires prior authorization (PA) for various services and drugs to ensure medical necessity and appropriate utilization. The requirements are detailed within specific service chapters of the Medicaid Services Manual (MSM). For instance, Chapter 600 outlines that Vagus Nerve Stimulation (VNS) therapy for individuals with intractable epilepsy requires prior authorization for the surgical procedure but not for devices or replacement parts. Similarly, Chapter 1300 specifies PA criteria for durable medical equipment (DME), prosthetics, orthotics, and supplies, necessitating documentation of medical necessity. Specific PA forms are also utilized, such as FA-1 for Durable Medical Equipment, which requires a medical order from the servicing provider and proof of a face-to-face clinical visit. FA-6 for Outpatient Medical/Surgical services mandates medical necessity documentation without specific thresholds or step therapy. Behavioral health outpatient services (FA-11) require initial or concurrent authorization with detailed treatment history and rationale. ## 2. How NV publishes and reports PA Nevada Medicaid primarily publishes PA criteria through the Medicaid Services Manual (MSM), organized into numbered service chapters covering hospital care, radiology, physician services, prescribed drugs, DME, and therapy. Each chapter provides specific guidelines on when PA is required and the documentation needed. The MSM is available through the Nevada Health Authority (NHA) website (the dhcfp.nv.gov link was noted as inactive at the time of research). Documents are updated periodically, with effective dates specified in each chapter or form. For instance, Chapter 300 removed prior authorization for MRI, MRA, MRS, and PET scans on September 1, 2019, while Chapter 600 introduced PA criteria for VNS therapy effective April 1, 2026. ## 3. NV's CMS-0057-F and PA-reform compliance posture The source documents do not provide specific details about Nevada's CMS-0057-F compliance or PA reform efforts. The state has implemented various changes over time, such as removing prior authorization for certain imaging services (Chapter 300) and updating criteria for other services like VNS therapy (Chapter 600), and uses specific PA forms (FA-1, FA-6), indicating a structured approach. The carve-out details suggest a complex system with different entities handling various aspects of the program — pharmacy services carved in to MCOs with a single state prescription drug list, while behavioral health has service-level carve-outs. (WISeR not applicable — NV is not one of the six WISeR-model states.) ## 4. How NV runs its own program Nevada's Medicaid program is managed under the Nevada Health Authority (NHA), which oversees the Medicaid Services Manual (MSM) and PA processes. The state has multiple MCOs handling different carve-ins (pharmacy, behavioral health). The fiscal agent history indicates transitions between ACS-Inc and Conduent/Gainwell. The state also operates several 1115 waivers, including the OUD/SUD Transformation Project, Whole Mouth Whole Body Connection for Adults with Diabetes, Nevada Comprehensive Care Waiver (NCCW / HCGP), and the Housing Pilot. Long-term services and supports (LTSS) are carved out to fee-for-service (FFS). ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Structured PA Criteria:** Nevada uses detailed MSM service chapters to outline PA requirements. - **Specific Forms:** FA-1, FA-6, etc. indicate a structured PA process. - **Frequent Updates:** Effective dates suggest NV regularly updates its PA criteria. ### What's Missing/Uncertain: - **WISeR:** Not applicable — NV is not a WISeR-model state. - **Gold Card Law:** Details missing. - **Foster Care Program Model:** Specifics unclear. - **CMS-0057-F Compliance:** No information in the sources. - **Detailed Codes and Thresholds:** Many documents do not specify CPT/HCPCS codes or thresholds.