Nevada updates outpatient prior authorization

Nevada Medicaid will require physician prior authorization (PA) for certain outpatient facility claims starting December 15, 2025. This update affects providers submitting claims for specified outpatient services. Claims submitted without an approved PA after this date risk denial or rejection.

Key changes for outpatient services

The new policy adds a PA mandate for designated outpatient facility services. Providers, including those offering behavioral health or IDD support, must secure physician authorization before delivering these services. This represents a shift from prior practices where outpatient claims were routinely payable without prior review.

Impact on providers and workflows

IDD and behavioral health agencies operating in Nevada should anticipate adjustments to existing processes. Scheduling, documentation, and billing workflows may require modification to incorporate PA verification steps. Providers must confirm authorization status before service delivery to avoid claim denials.

Recommendations for compliance

To align with the update, agencies should review relevant Nevada Medicaid billing protocols and familiarize themselves with affected outpatient service categories. PA requests must be submitted through the designated provider portal or as specified by Nevada Medicaid. Incorporating PA confirmation into intake or service planning procedures is advised to streamline compliance and reduce claim processing issues.

This policy update underscores the importance of proactive PA management for outpatient claims in Nevada Medicaid, particularly among IDD and behavioral health service providers.