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The FA 24 form serves as an essential document for those seeking Personal Care Services (PCS) under Nevada Medicaid. This request form plays a pivotal role in initiating various types of authorizations, including updates for annual visits, temporary service requests, and significant changes in the recipient's health condition. It is crucial for users to navigate the Provider Web Portal for upload and access instructions while being aware of the specific sections that need to be completed. Detailed recipient information is required, including last name, first name, Medicaid ID, and contact details. Additionally, the form also addresses the legally responsible individual (LRI) and their involvement in the care process, if applicable. Moreover, an alternate contact for scheduling is necessary to ensure consistent communication. This form emphasizes the importance of providing accurate details regarding diagnoses that impact the recipient's ability to perform daily tasks and any recent incidents that may have occurred. The comments section allows for further clarification, ensuring that assessors receive comprehensive information for their evaluations. It is vital to remember that this form does not guarantee payment and contains confidential provisions for its content.

Fa 24 Example

Nevada Medicaid and Check Up

Authorization Request for Personal Care Services (PCS)

Upload this request through the Provider Web Portal.

Questions? Call: (800) 525-2395

For information on completing this form, see the instructions online at www.medicaid.nv.gov (select “Forms” from the “Providers” menu, then click on Form Number FA-24-I).

DATE OF REQUEST: ____/____/______

SECTION 1: FOR NEVADA MEDICAID USE ONLY

SECTION 2: PURPOSE OF REQUEST

Update Visit (annual)

Significant Change in Condition

Temporary Service Authorization

One-Time Service

Information Only

___________________________

___________________________

___________________________

Cancel Authorization

Agency’s last date of service:

____/____/_______

Reason:

Recipient Ineligible

 

Recipient Expired

 

Other: __________________

SECTION 3: CONTACT INFORMATION

RECIPIENT INFORMATION

Last Name:

 

 

First Name:

 

 

 

 

Recipient Medicaid ID:

 

 

Date of Birth:

 

 

 

 

Translator Required:

Yes

No

Language:

 

 

 

 

Address:

 

 

 

City:

State:

Zip Code:

Phone:

PCS AGENCY INFORMATION

PCS Agency Name:

 

City:

 

 

 

 

NPI/API:

Phone:

 

Fax:

 

 

 

 

LEGALLY RESPONSIBLE INDIVIDUAL (LRI) INFORMATION (if applicable*)

*Complete this section if the definition of LRI is met. Individuals who are legally responsible to provide medical support, including spouses of recipients, legal guardians [not power of attorney (POA)], and parents of minor recipients, including stepparents, foster parents and adoptive parents. Attach a completed copy of form FA-24B (LRI Availability Determination for the Personal Care Services Program) with any submitted request when the recipient resides with an LRI. It is the responsibility of the provider to attach a current work note (availability) or a copy of the permanent disability form or an updated disability form if the disability was/is temporary (capability). If this section is not addressed and appropriate paperwork not attached, this request will be denied and the form will be returned to the provider. See the FA-24 Instructions on the Forms webpage at www.medicaid.nv.gov for additional instructions regarding this section.

Does recipient have an LRI? (see definition above)

 

Yes

No

Unknown

 

 

 

 

 

 

 

 

 

 

 

LRI Name:

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

Relationship to Recipient:

 

 

 

 

Does LRI reside with recipient?

Yes

No

 

 

 

 

 

 

 

 

Is the LRI also on the PCS Program:

Yes

No

 

 

 

Receives_________ hrs/wk

 

 

 

 

 

 

 

LRI Employment Status:

Employed

# Hrs/wk:_____ Days Off:_______

Unemployed

Disabled

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FA-24

 

 

 

 

 

 

 

 

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Nevada Medicaid and Check Up

Authorization Request for Personal Care Services (PCS)

Recipient Name:

Recipient Medicaid ID:

ALTERNATE CONTACT INFORMATION

(An alternate contact is needed for scheduling purposes in the event the recipient and/or LRI are unavailable.)

Alternate Contact Name:

Phone:

Relationship to Recipient:

 

 

 

 

 

 

Can this person be contacted in case we are unable to contact recipient?

Yes

No

 

 

 

 

SECTION 4: DIAGNOSES AND INCIDENTS

 

 

 

 

 

 

 

 

 

 

 

DIAGNOSIS/DIAGNOSES AFFECTING THE INDIVIDUAL’S ABILITY TO COMPLETE TASKS:

Is anyone else in the home receiving PCS at this time?

 

 

Yes - Who:_________________________________________________

No

Unknown

INCIDENTS, INCLUDING A SUMMARY OF ALL REPORTED SERIOUS OCCURRENCES, WITHIN PAST 90 DAYS (Check all that apply. The Summary of Reported Serious Occurrences section is mandatory.)

Hospitalization

Discharged date or anticipated discharge date: ________________________

 

 

 

 

Recent Fall

 

Surgery Type:________________________________

Loss of non-paid caregiver

 

 

 

New Medical Condition/Diagnosis (specify):

 

 

 

Addition or loss of other services (specify):

 

Summary of Reported Serious Occurrences: ________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

No Serious Occurrences

SECTION 5: COMMENTS (General comments that would assist an assessor in completing an accurate assessment; include reason for request):

SECTION 6: PERSON COMPLETING/SUBMITTING THIS REQUEST (This person will be contacted with questions or if additional information is needed to process this request.)

Name:

Phone:

FA-24

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Updated 08/23/2021 (pv01/29/2019)

 

Nevada Medicaid and Check Up

Authorization Request for Personal Care Services (PCS)

SECTION 7: PERSONAL CARE ATTENDANT (PCA) INFORMATION (An LRI cannot be a PCA) (Mandatory fields)

PCA Name:

PCA Phone Number:

 

 

(cannot be the agency’s phone number)

 

 

 

 

 

 

 

 

 

PCA is a relative:

Yes

No

If Yes, what is the relationship:

 

 

 

 

 

 

 

 

 

PCA resides:

In home

Out of home

 

PCA is not related but lives in home:

Yes

No

 

 

 

 

 

 

PCA is not related and is not living with recipient:

Yes

No

 

 

 

 

 

 

 

 

 

SECTION 8: ADDITIONAL COMMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The information contained in this form, including attachments, is privileged and confidential and 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 agent responsible to deliver it 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. This referral/authorization is not a guarantee of payment.

FA-24

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Updated 08/23/2021 (pv01/29/2019)

 
Get Fa 24 PDF Form

Form Characteristics

Fact Name Description
Form Purpose The FA 24 form is used for requesting authorization for Personal Care Services under Nevada Medicaid and Check Up programs.
Submission Method Requests must be uploaded through the Provider Web Portal.
Contact Information Questions regarding the form can be directed to the number (800) 525-2395.
Eligibility Requirements Completion of the form is mandatory for all individuals seeking personal care services under the Medicaid program.
Legally Responsible Individual The form contains a section for individuals who are legally responsible for the recipient, such as spouses and legal guardians.
Diagnosis Summary A summary of diagnoses affecting the individual's ability to complete tasks must be provided, alongside a report of any serious incidents.
Disclosure Policy The information provided in the form is confidential and privileged, intended only for the designated entities.
Service Types The form allows for a variety of requests, including updates, one-time services, and information-only requests.
Exemption Note If all parts of the form are not completed, the request may be denied and returned to the provider.

Guidelines on Utilizing Fa 24

Completing the FA-24 form is a vital step in requesting authorization for personal care services through Nevada Medicaid. Before proceeding, ensure that you have all necessary information and documentation at hand. This guide outlines the necessary steps to fill out the form accurately.

  1. Write the date of the request at the top in the format ____/____/______.
  2. In Section 2, check the appropriate box that describes the purpose of your request. Options include: Update Visit, Significant Change in Condition, Temporary Service Authorization, One-Time Service, Information Only, or Cancel Authorization. If canceling, provide the Agency’s last date of service and reason.
  3. In Section 3, fill out the recipient's information. Include their last name, first name, Medicaid ID, date of birth, and indicate if a translator is required. If yes, specify the language. Also, provide the recipient’s address, city, state, zip code, and phone number.
  4. Next, enter the details of the Personal Care Services Agency by stating the agency name, city, NPI/API number, phone, and fax.
  5. If applicable, complete the Legally Responsible Individual (LRI) section. Indicate whether the recipient has an LRI, provide their name, phone number, relationship to the recipient, and whether they reside with the recipient. Include LRI’s employment status and hours worked per week.
  6. List the alternate contact information, including the alternate contact’s name, phone number, and relationship to the recipient. Also, indicate if this person can be contacted if the recipient and LRI are unavailable.
  7. In Section 4, detail the diagnoses affecting the individual. State whether anyone else in the home is receiving PCS, and if so, provide their names. Note any incidents from the past 90 days, including hospitalizations, falls, surgeries, or other significant occurrences.
  8. If there are comments that would assist an assessor, include them in Section 5.
  9. In Section 6, input the name and phone number of the person completing the request.
  10. In Section 7, fill in the Personal Care Attendant (PCA) information. This includes the PCA's name, phone number (not the agency’s number), and confirm if they are a relative or an unrelated person residing in or out of the home.
  11. Finally, add any additional comments in Section 8 that may be relevant to the request.

Once you have completed the form, review it for accuracy before submitting it through the Provider Web Portal. For any questions during the process, you can contact the helpline at (800) 525-2395.

What You Should Know About This Form

What is the FA 24 form used for?

The FA 24 form is the Nevada Medicaid and Check Up Authorization Request for Personal Care Services (PCS). It is used to request authorization for personal care services for individuals who are eligible for Medicaid. This form helps providers request updates, temporary services, or even one-time services when needed.

How do I submit the FA 24 form?

You can upload the completed FA 24 form through the Provider Web Portal. If you have any questions or need assistance, you can call 800-525-2395 for help. Make sure to follow the instructions provided online at www.medicaid.nv.gov, under the "Forms" section.

What information is required on the FA 24 form?

The form requires several details, including the recipient's personal information (name, Medicaid ID, and contact info), the purpose of the request, and any diagnoses or incidents affecting the individual’s ability to complete tasks. You also need to provide information about the Personal Care Attendant (PCA) and any legally responsible individuals (LRI) involved.

What happens if the LRI section is not completed?

If you do not complete the LRI section and attach the necessary documents, your FA 24 request will be denied. This means it is important to include all relevant details and supporting paperwork to ensure the request is processed smoothly.

Is the FA 24 form confidential?

Yes, the information contained in the FA 24 form is privileged and confidential. It is intended solely for the use of the individual or entities named on the form. Unauthorized dissemination, distribution, or copying of this information is strictly prohibited.

Can an LRI also be a Personal Care Attendant (PCA)?

No, an LRI cannot serve as a PCA. These roles are distinct and must be filled by different individuals. This is an important detail to keep in mind when completing the form to ensure compliance with Medicaid guidelines.

What should I do if I have additional comments or information?

The form includes a section for additional comments. Use this space to provide any general comments that might assist in the assessment process or to explain the reason for your request in more detail.

Does submitting the FA 24 form guarantee payment for services?

No, submitting the FA 24 form does not guarantee payment for services. This referral or authorization is a request, and payment will depend on various factors, including eligibility and coverage. Ensure you review all guidelines and eligibility requirements before assuming coverage.

Common mistakes

Filling out the FA-24 form for Nevada Medicaid can be a straightforward process, but many people make common mistakes that can lead to delays or denials. One major mistake is failing to provide accurate recipient information. This includes the recipient's full name, Medicaid ID, and date of birth. It’s crucial that all details match the information on file with Medicaid. Even small typographical errors can result in processing issues.

Another frequent error involves neglecting to complete the section on diagnosis and incidents. This section requires detailed information about the individual’s condition and any serious incidents they have experienced in the past 90 days. Omitting this information can hinder the assessment process. Including a comprehensive summary is essential to ensure assessors have all the necessary context.

Many individuals do not attach required documentation, particularly for legally responsible individuals (LRI). If applicable, you must submit the FA-24B form alongside the FA-24. Failing to do so may result in the request being denied outright. It’s important to check that any related paperwork has been included before submitting. Missing documents can cause unnecessary delays, requiring you to start the process over again.

People often overlook the importance of providing correct contact information for the personal care attendant (PCA). If the PCA needs to be reached for questions or further information, their details should be clearly stated. This includes their name and phone number, which must not be the same as the agency’s contact information. An incorrect or incomplete PCA section can also lead to issues.

Lastly, many applicants fail to utilize the comments section effectively. This is an opportunity to provide additional context or clarification that could assist assessors during their review. Specifying the reason for the request or highlighting any urgent needs can make a significant difference in how the request is processed. Ignoring this section means missing the chance to advocate for any special considerations related to the request.

Documents used along the form

When submitting the FA-24 form, it’s important to know that several other forms and documents may accompany it to ensure a thorough review and approval process. Each of these documents serves a specific purpose related to personal care services, providing essential information about the recipient and their care needs. Below is a list of commonly used forms that are often submitted alongside the FA-24.

  • FA-24B (LRI Availability Determination for the Personal Care Services Program): This form is critical if the recipient has a legally responsible individual (LRI) living with them. It assesses whether the LRI can provide medical support.
  • FA-24C (Personal Care Attendant - PCA Information): Used to provide details about the personal care attendant who will assist the recipient. It includes the PCA's contact information and their relationship to the recipient.
  • FA-24D (Personal Care Services Plan): This document outlines the specific services and the frequency of those services the recipient requires. It helps in defining the care plan tailored to the individual’s needs.
  • FA-24E (Physician’s Certification for Personal Care Services): A physician must complete this certification to validate the medical necessity of the personal care services being requested, ensuring that they align with the recipient’s health status.
  • Medicaid Eligibility Verification: A document that confirms the eligibility of the recipient for Medicaid services. It must be current to avoid delays in processing the FA-24 request.
  • Caregiver Employment Documentation: If a caregiver is being paid for their services, this document provides proof of their employment status and the number of hours worked, which can impact service approval.
  • Incident Report Form: If there have been any significant incidents affecting the recipient's condition—such as hospitalization or major falls—this report provides necessary details that may influence the service authorization decision.

Ensuring that these forms are accurately completed and submitted with the FA-24 is crucial for a smooth approval process. Taking the time to gather all necessary documentation can help avoid delays in receiving essential care services.

Similar forms

  • Form FA-24B: LRI Availability Determination for the Personal Care Services Program - This document is essential when the recipient resides with a legally responsible individual. It requires detailed information regarding the LRI's availability to provide necessary support, ensuring more comprehensive caregiver assessments.
  • FA-27: Personal Care Services (PCS) Assessment Form - Similar to the FA-24 form, the FA-27 assesses the specific needs of the individual requiring care. It gathers detailed information about care requirements and helps determine the level of services needed.
  • FA-25: Medicaid Application Form - While primarily for applying for Medicaid benefits, the FA-25 collects information regarding the individual’s eligibility, which is a basic requirement before proceeding with any care service authorization.
  • FA-26: Eligibility Verification Request - Like the FA-24, the FA-26 is used to confirm an individual’s eligibility for Medicaid services. This verification is crucial before any personal care service can commence.
  • FA-28: Personal Care Services Documentation Form - This document is necessary for tracking the care services provided. It complements the FA-24 by ensuring the ongoing recorded activities align with authorized services.
  • FA-29: Incident Report for Personal Care Services - It is imperative to address any incidents that occur during the provision of services. The FA-29 aids in documenting such occurrences, serving as a critical companion to the updates requested in the FA-24.
  • FA-30: Request for Review Form - Similar in nature, this form allows for the review and reconsideration of previously made decisions regarding care services. Understanding the outcomes of initial requests is vital for ongoing service management.

Dos and Don'ts

Things You Should Do:

  • Read the instructions carefully before starting the form.
  • Fill out all required sections completely and accurately.
  • Use clear and legible handwriting if filling out by hand.
  • Provide the correct recipient Medicaid ID for proper identification.
  • Include all necessary supporting documents with your submission.

Things You Shouldn't Do:

  • Don’t leave any required fields blank.
  • Don’t submit the form without double-checking for errors.
  • Avoid using abbreviations that may not be clear.
  • Do not forget to include an alternate contact if needed.
  • Never assume that an incomplete form will be processed correctly.

Misconceptions

Many people hold misconceptions about the FA 24 form, which can lead to confusion or mistakes during the application process. Below are some common misconceptions, along with clarifications to address them.

  • The FA 24 form can be submitted through any method. Many assume that they can submit the FA 24 form via mail or in person. However, it must be uploaded through the designated Provider Web Portal.
  • All requests require the same documentation. Some individuals believe that the documentation required for every authorization request is the same. In reality, the FA 24 form often requires different supporting documents based on the specific situation or request.
  • Anyone can assist with the form without specific knowledge. It is a common belief that any family member or friend can fill out the FA 24 form accurately. However, it is crucial that the person completing the form understands the requirements and includes all necessary information to avoid delays or denials.
  • The FA 24 form guarantees approval for services. Some people think submitting the FA 24 form guarantees that services will be authorized. However, this form is just a request, and approval depends on the assessment of eligibility and necessity.
  • Contacting the number provided offers personal assistance. Many individuals assume that calling the number on the form will connect them directly with someone who can answer specific questions about their personal situation. Instead, this number is typically for general inquiry purposes and not customized support.
  • Legal responsibilities are not clearly defined. There is a misconception that all individuals listed as legally responsible individuals (LRI) are automatically recognized on the FA 24 form. It is essential to understand the specific criteria for being considered an LRI and to provide all required information and documentation as needed.

Key takeaways

When filling out the FA-24 form for Nevada Medicaid's Personal Care Services (PCS), it’s important to keep several key points in mind:

  • The FA-24 form should be uploaded through the Provider Web Portal.
  • If you have questions, a helpline is available: (800) 525-2395.
  • Always specify the purpose of your request clearly, choosing from options like annual updates or one-time services.
  • Ensure recipient information is complete, including their Medicaid ID and date of birth.
  • If applicable, include details on the Legally Responsible Individual (LRI) and attach necessary documents.
  • Document any recent incidents, including hospitalizations or falls, within the last 90 days.
  • Provide contact information for the person submitting the request, as they will be contacted for follow-up.
  • Remember that your submission does not guarantee payment; it is merely a request for authorization.

By following these takeaways, the process of submitting the FA-24 form can be smoother and more efficient.

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