Get Wps Medicare Part B Redetermination Request Form. Wps Medicare Part B Redetermination Request Form

The WPS Medicare Part B Redetermination Request Form is essential for individuals seeking to contest a decision made on their claim. This guide will provide clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to complete your redetermination request.

1. Click ‘Get Form’ button to obtain the form and open it for review.
2. State where the service was performed by selecting your state from the options provided (MI or IN).
3. In the provider information section, enter the required details, including the provider transaction access number (PTAN), national provider identifier (NPI), last five digits of the tax ID, name, address, city, state, and ZIP code.
4. Fill in the beneficiary information by providing the patient's telephone number, name, and Medicare health insurance claim number (HICN).
5. Complete the claim information section, including the date of the initial determination notice, reason for late submission (if applicable), internal control number (ICN), date of service, CPT/HCPCS code, and billed amount.
6. Specify the reason for your request, indicating dissatisfaction with the original claim determination and detailing the reasons in the provided space.
7. Indicate whether you have additional information to submit by selecting 'Yes' or 'No' and attach appropriate documentation if necessary.
8. In the requestor information section, provide the name of the claimant or representative, telephone number and extension, and the signature of the person appealing along with the date signed.
9. Finally, submit the completed form by faxing or mailing it to the appropriate address indicated on the form. Ensure you send it to the correct WPS Medicare Part B address for your state.

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