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Nevada - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

Nevada restricts the provision of Targeted Case Management (TCM) for adults with serious mental illness to employees or contractors of a state agency, local county agency, or the Nevada University Health System under State Plan Amendment 23-0009. Providers seeking to deliver these services must operate under the direct umbrella of these designated public or university entities, effectively closing the market to independent private agencies for this specific target group.

Approval to bill for these services requires enrollment through the Division of Health Care Financing and Policy (DHCFP) as a Provider Type 47 (Targeted Case Management) or Provider Type 95 (HCBS Waiver Case Management). Applicants must secure a Nevada Secretary of State Business ID, pass an initial site visit from DHCFP or the Aging and Disability Services Division (ADSD) to verify HCBS Settings Rule compliance, and ensure all rendering staff hold specific professional licenses such as an RN or LCSW.

1. Service Definition and Scope

In Nevada, Case Management is defined as services furnished to assist individuals eligible under the State Plan in gaining access to needed medical, social, educational, and other services. This includes comprehensive assessment, periodic reassessment, care planning, referral, and monitoring.

The service is delivered either as Targeted Case Management (TCM) for specific populations like adults with serious mental illness, or as HCBS Waiver Case Management under waivers such as the Waiver for Individuals with Intellectual and Developmental Disabilities.

2. Regulatory and Oversight Agencies

The primary Medicaid agency in Nevada is the Division of Health Care Financing and Policy (DHCFP), which oversees provider enrollment, policy creation, and quality assurance. The Aging and Disability Services Division (ADSD) partners with DHCFP to manage and oversee HCBS waiver programs.

These agencies jointly conduct site visits and annual reviews to ensure compliance with the Medicaid Services Manual (MSM) and the HCBS Settings Rule.

3. Gatekeeping Prerequisites: Who Can Even Apply

Nevada imposes strict structural preconditions on who can enroll as a Targeted Case Management provider for certain populations. Under SPA 23-0009, TCM for adults with serious mental illness is restricted to specific public and university entities.

Independent private agencies cannot enroll directly to provide TCM to this target group unless they are contracted under one of the designated entities.

4. Licensure and Certification Requirements

Nevada does not issue a distinct "Case Management Agency" license. Instead, the state relies on the professional licensure of the rendering staff and the organizational certification of the overarching state or county agency.

Providers must maintain active professional licenses issued by the appropriate Nevada state boards for all rendering practitioners.

5. Medicaid Provider Enrollment

Agencies must enroll through the Nevada Medicaid Provider Web Portal. Case management services are typically billed under Provider Type 47 (Targeted Case Management) or Provider Type 95 (HCBS Waiver).

The enrollment process requires submission of the agency's NPI, Secretary of State Business ID, and an Electronic Funds Transfer (EFT) authorization form.

6. Staffing, Training and Background Checks

Rendering case managers must meet strict educational and professional criteria. Nevada Medicaid requires case managers to possess the knowledge and skills to fulfill assessment and information gathering elements.

Unlicensed staff may only provide services if they meet specific educational requirements and work under direct supervision.

7. Documentation, Policies and Records

Providers must maintain comprehensive case records that document all case management activities. These records are subject to 100% annual review by DHCFP and ADSD Quality Assurance units.

Documentation must clearly show that case management activities are not an integral and inseparable component of another covered Medicaid service.

8. Billing, Rates and Claims

Reimbursement for case management is governed by Medicaid Services Manual (MSM) Chapter 700. Providers must indicate during enrollment whether they will serve Fee For Service (FFS) recipients, Managed Care Organization (MCO) recipients, or both.

Payment for targeted case management cannot duplicate payments made to public agencies or private entities under other program authorities for the same purpose.

9. Approval Sequence and Timeline

The approval sequence begins with securing the required state/county agency affiliation or contract, followed by obtaining a Nevada Secretary of State Business ID. The agency then submits the enrollment application via the Nevada Medicaid portal.

Prior to final enrollment approval, DHCFP conducts an on-site visit to ensure the new provider complies with the HCBS Settings Rule.

10. Common Denials and Survey Findings

Applications are frequently returned for corrections if the Medicare enrollment answers do not match throughout the application or if the EFT form lacks a voided check or bank letter.

During site visits and annual reviews, providers face termination if they fail to comply with the HCBS Settings Rule, such as failing to ensure recipient privacy or access to food.

11. Key Contacts and Resources

Prospective providers should utilize the official Nevada Medicaid portal for enrollment checklists and the DHCFP website for the Medicaid Services Manual.

Questions regarding waiver-specific qualifications should be directed to the Aging and Disability Services Division.

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