Get Wps Medicare Part A Overpayment Refund Form. Wps Medicare Part A Overpayment Refund Form

Filling out the WPS Medicare Part A Overpayment Refund Form is essential for accurately processing overpayment refunds. This guide provides clear instructions to assist users in completing the form online with confidence.

Follow the steps to effectively complete the WPS Medicare Part A Overpayment Refund Form.

1. Click ‘Get Form’ button to obtain the WPS Medicare Part A Overpayment Refund Form and open it in the editor.
2. Complete the 'From' section by entering your provider or supplier name, street address, city, state, and ZIP code. Include your PTAN/provider number and Tax Identification Number (TIN). Additionally, provide the contact name and telephone number.
3. In the 'Check/Refund Information' section, fill in the amount of the check, refund check number, and check date. You must then provide details for each claim, including patient name, HICN, date of service, Medicare claim number, claim amount refunded, and reason code.
4. If specific patient, HICN, or claim number information is not available due to statistical sampling, indicate the methodology and formula used to determine the overpayment's amount and reason.
5. In the OIG Reporting Requirements section, specify whether the refund is the result of a Corporate Integrity Program and/or an OIG Self-Disclosure Program by checking 'Yes' or 'No.'
6. For institutional facilities, complete the cost report year information. If Medicare requested this refund, indicate 'Yes' or 'No' and include the Accounts Receivable Number if applicable.
7. Check the appropriate reason code for the refund from the provided list. If 'Other' is selected, please specify the reason.
8. Review the completed form for accuracy and ensure all required fields are filled out before submitting it.
9. Once the form is completed, save your changes, then download, print, or share the document as needed.

Complete your WPS Medicare Part A Overpayment Refund Form online today to ensure a smooth refund process.