Get Or Health Net Xo-paf-1650 2019

Filling out the OR Health Net XO-PAF-1650 form online can streamline the process of requesting necessary health services. This guide will walk you through each component of the form, ensuring that you understand what information is required and how to provide it accurately.

Follow the steps to complete the OR Health Net XO-PAF-1650 online

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by entering the member's date of birth in the designated field. Ensure to use the format MMDDYYYY.
3. Fill in the member ID field with the correct member identification number, identified as *1650*.
4. Provide the requesting provider's information, including their NPI (National Provider Identifier), contact name, TIN (Tax Identification Number), and fax and phone number.
5. If the servicing provider is different, uncheck the 'Same as Requesting Provider' box and enter their information, including NPI, contact name, TIN, and fax and phone number.
6. Under the authorization request section, enter the primary procedure code (CPT/HCPCS) and include any modifiers necessary.
7. If there are additional procedure codes, fill in the corresponding fields as needed, ensuring all relevant modifiers are included.
8. Specify the start date or admission date in MMDDYYYY format, followed by the end date or discharge date if applicable.
9. Select the outpatient service type from the provided list by entering the corresponding service type number.
10. Input the diagnosis code with the ICD-10 format and indicate the total units, visits, or days required for the request.
11. Ensure all required fields marked with an asterisk (*) are filled in completely, as incomplete forms will be rejected.
12. Review the form for accuracy, then proceed to save changes, download, or print the form for submission.

Complete your forms online today to ensure timely processing of your health requests.