Get Oklahoma Healthcare Authority Form

The Oklahoma Healthcare Authority Form is a crucial document for managing healthcare claims adjustments. This guide will provide you with comprehensive, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the Oklahoma Healthcare Authority Form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter your 9-digit billing provider number and 1 character service location in the Provider Number section.
3. Provide your current billing name and address in the Provider Name/Address section.
4. Input the phone number of the contact person in the Phone Number field.
5. Select the appropriate reason for adjustment by checking the corresponding box.
6. Enter the Internal Control Number (ICN) of the claim you wish to adjust, which can be found on the Remittance Advice.
7. Input the 9-digit identification number of the recipient in the Client ID No. field.
8. Fill in the From and Thru Dates of Service as billed on the claim.
9. Enter the first and last name of the recipient in the Client Name section.
10. Input the paid amount of the claim to be adjusted in the Amount Paid field.
11. Enter the date of your Remittance Advice on which the claim last paid in the Remittance Advice Date section.
12. Provide a clear explanation for the requested adjustment or refund in the Explanation field.
13. Check the appropriate box for the type of adjustment you are requesting.
14. Select the appropriate claim type to be adjusted by checking the corresponding box.
15. Select the program associated with the claim to be adjusted.
16. If adjustment data pertains to a specific line on the claim, enter the line number; if not, enter zero (0) in the Line No. field.
17. Briefly describe the data that needs to be corrected in the Description of Information to be Corrected section.
18. Enter the current information as stated on the current claim that needs to be adjusted.
19. Provide the corrected information for the claim in the Corrected Information field.
20. Enter the signature of the appropriate person and the date you are submitting this request.
21. Once all information is filled out, users can save changes, download, print, or share the form as needed.

Complete your Oklahoma Healthcare Authority Form online for a streamlined process.