Get Or Health Net Xo-paf-1650 2020-2025

The OR Health Net XO-PAF-1650 form is essential for requesting authorization for Part B drugs. This guide provides clear, step-by-step instructions on how to fill out the form accurately and efficiently.

Follow the steps to complete the form correctly.

1. Press the 'Get Form' button to obtain the OR Health Net XO-PAF-1650 form and open it in the editor.
2. Enter the member information in the designated fields. This includes the member's date of birth in the format MMDDYYYY, member ID, and their last name followed by their first name.
3. Provide the requesting provider information. Fill in the requesting NPI, contact name, TIN, and provider name. Ensure that all fields marked with an asterisk are completed as these are required.
4. If the servicing provider or facility is different, provide their NPI, name, and phone number. If it is the same, you may skip this section.
5. Complete the authorization request section. Specify the primary procedure code and any additional procedure codes required. Make sure to include any modifiers as necessary.
6. Indicate the type of outpatient service you are requesting by selecting from the drop-down options. Include start and end dates or admission and discharge dates, as well as diagnosis codes.
7. Fill in the total units, visits, or days required for the request. It is crucial to enter all required fields accurately, as incomplete forms will be rejected.
8. Attach any supporting clinical information that is pertinent to the request. Lack of clinical information may result in delayed determinations.
9. Once all fields are complete and verified, you can save your changes, download a copy for your records, print the form for submission, or share as necessary.

Start completing your OR Health Net XO-PAF-1650 form online today for a smooth authorization process.