Get Wps Medicare Part B Msp Refund Form. Wps Medicare Part B Msp Refund Form

Filling out the WPS Medicare Part B MSP Refund Form correctly is crucial for ensuring timely refunds. This guide provides clear, step-by-step instructions tailored to assist users through each section of the form.

Follow the steps to complete your refund request efficiently.

1. Press the ‘Get Form’ button to access the WPS Medicare Part B MSP Refund Form and open it for completion.
2. In the 'To' section, enter the name and address of WPS GHA MSP, P.O. Box 8002, Madison, WI 53708-8002. This identifies where the refund request is being sent.
3. Fill in the 'From' section with your provider or supplier name and address. Ensure all details are accurate to avoid processing delays.
4. Complete the 'City, State, Zip Code' and 'Contact Name' fields. Supply your 'PTAN,' 'Telephone Number,' and 'Tax Identification Number (TIN)' for proper identification.
5. On the form, indicate the 'Amount of Check,' 'Refund Check #,' and 'Check Date.' This information is essential for processing the refund.
6. Answer whether Medicare requested this refund by selecting 'Yes' or 'No.' If 'Yes,' include the Accounts Receivable Number, found in your letter from Medicare.
7. For OIG Reporting Requirements, indicate if the refund is related to a Corporate Integrity Program or an OIG Self-Disclosure Program by checking 'Yes' or 'No' as applicable.
8. In the 'Reason Code for Refund' section, check the appropriate reason for the refund from the provided options (e.g., Working Aged, Auto/No Fault, etc.).
9. Fill in the patient’s name, HICN, date of service, Medicare claim number, and claim amount refunded accurately to ensure a rightful claim.
10. Attach a copy of the primary payer Explanation of Benefits (EOB) and ensure that all required patient-specific information is complete.
11. Review all entries for accuracy and completeness. Once verified, you can save changes, download, print, or share the form as needed.

Begin filling out your WPS Medicare Part B MSP Refund Form online today.