
Get Wps Gha Part B Redetermination Request Form
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How to fill out the WPS GHA PART B REDETERMINATION REQUEST FORM online
The WPS GHA Part B Redetermination Request Form is an essential document for submitting a request for a reconsideration of a Medicare claim determination. This guide provides a clear, step-by-step approach to completing the form online, ensuring that you can effectively appeal a decision regarding your claim.
Follow the steps to complete the form accurately online.
- Click the ‘Get Form’ button to access the form, opening it in your preferred online editing tool.
- Indicate the state where the service was performed by selecting one of the options: IA, KS, MO, or NE.
- Enter the provider information. Complete all required fields 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. Ensure all information is accurate to avoid dismissal of your request.
- Fill in the beneficiary information by providing the patient/beneficiary's name, Medicare Health Insurance Claim Number (HICN), and their telephone number.
- Complete the claim information section. Provide the date of the initial determination notice, the reason for late submission if applicable, the Internal Control Number (ICN), date of service, CPT/HCPCS codes, and the billed amount.
- In the reason for request section, state your dissatisfaction with the original claim determination. You may indicate whether you have additional information to submit by checking ‘Yes’ or ‘No’. If yes, ensure to attach the relevant documentation.
- Fill in your requestor information. Include the name of the claimant or representative, their telephone number with extension, their signature, and the date signed.
- Review the completed form for accuracy. Once all fields are filled out, save your changes. You may download, print, or share the form as needed. Make sure to follow any instructions for submitting the completed form via fax or mail.
Begin filling out your WPS GHA Part B Redetermination Request Form online today.
A redetermination must be requested in writing....Make a written request containing all of the following information: Beneficiary name. Medicare number. Specific service(s) and/or item(s) for which a redetermination is being requested. Specific date(s) of service. Name of the party, or the representative of the party.
Fill WPS GHA PART B REDETERMINATION REQUEST FORM
WPS GHA Part B Redetermination Request Form. All fields are REQUIRED. Use this form to request a redetermination (1st level of appeal) if dissatisfied with the initial determination of a claim. Use this form to request a redetermination if dissatisfied with an initial claim determination or overpayment decision. To submit a redetermination request, you must use a specific claim. Once logged in, use the claim inquiry link to find the claim. Please attach the evidence to this form or attach a statement explaining what you intend to submit and when you intend to submit it. How to Appeal a Claim Determination. Claims Reconsideration Form. Download Redetermination Request Form - J5A.
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