Get Immediate Recoupment Request Form - Wps

This guide provides clear and detailed instructions on how to fill out the Immediate Recoupment Request Form for WPS Medicare online. By following these steps, you can ensure that your request for immediate recoupment is processed efficiently and without error.

Follow the steps to complete the Immediate Recoupment Request Form online.

1. Press the ‘Get Form’ button to access the Immediate Recoupment Request Form - WPS online.
2. Begin by entering the letter number associated with your request. This number can be found on the demand letter you received.
3. Fill in the letter date, ensuring you double-check the date format for accuracy.
4. Provide your name as the provider in the designated field.
5. Enter your provider PTAN (Provider Transaction Access Number) accurately.
6. List your provider NPI (National Provider Identifier) number to ensure correct identification.
7. Input the last five digits of your provider's TIN (Tax Identification Number) as required.
8. Fill in your contact name along with your contact phone number, including any necessary extension.
9. If applicable, mark the box to indicate your preference for all future overpayments to be set up for immediate recoupment.
10. If desired, indicate whether you would like to discontinue immediate recoupment for all future overpayments.
11. Review the statement indicating your understanding of the waiver for potential interest payment associated with the overpayments before signing.
12. Provide your signature along with the date of submission to finalize the request.
13. Save your changes, then download, print, or share the completed form as needed.

Complete your Immediate Recoupment Request Form online to ensure prompt processing of your request.