Loading
Get Wps Medicare Refund Form
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the WPS Medicare Refund Form online
The WPS Medicare Refund Form is essential for requesting refunds under Medicare. This guide provides a clear, step-by-step approach to help you fill out the form accurately and submit it online.
Follow the steps to complete the WPS Medicare Refund Form.
- Click the ‘Get Form’ button to obtain the WPS Medicare Refund Form and open it for editing.
- In the 'From' section, enter the provider or supplier name and address. Make sure to include the necessary details to ensure accurate identification.
- In the 'To' section, specify the appropriate WPS Medicare Part B address based on whether you are submitting from Indiana or Michigan.
- Fill in your City, State, and Zip Code in the respective fields, along with your Provider Transaction Access Number (PTAN) and Tax Identification Number (TIN).
- Provide your contact name and telephone number as well as the amount of the check you are requesting to refund.
- Indicate whether Medicare requested this refund by selecting 'Yes' or 'No'. If 'Yes,' include the Accounts Receivable Number found on your notification letter.
- Check the boxes to indicate the OIG reporting requirements applicable, if any, and briefly state the reason code for the refund by selecting the corresponding code.
- Fill out the patient information, including the patient's name, Health Insurance Claim Number (HICN), Medicare claim number, and the refund claim amount.
- Provide the date of service and include primary insurance details in the Medicare Secondary Payer section, ensuring to attach a copy of the primary payer's Explanation of Benefits (EOB).
- Finally, review all provided information for accuracy. Save changes, download, print, or share the completed form as necessary.
Compete your documents online efficiently to ensure timely processing of your Medicare refunds.
WPS Medicare supplement plans provide additional coverage for services not fully covered by traditional Medicare. These may include costs for hospital stays, doctor visits, and other health services. If you are exploring your coverage options or need to understand your benefits better, referencing your WPS Medicare refund form can provide clarity on claims.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.