Get Wps Refund Request Form

WPS Medicare Part B MSP Refund Form Include the check s to be refunded and a copy of the remittance notice NOTE A separate form is required for each patient. From To Indiana Payment Recovery P. O. Box 8811 Marion IL 62959-0910 Provider/Supplier Name Address Michigan City State Zip Code PTAN Tax Identification Number TIN Contact Name Amount of Check Telephone Number Refund Check Check Date Did Medicare Request This Refund Yes No If Yes indicate the Accounts Receivable Number this number is on your letter please include a copy of your letter OIG Reporting Requirements This refund is the result of a Corporate Integrity Program Reason Code for Refund Please check the reason for this refund 01 Working Aged 04 Auto/No Fault 02 ESRD 05 Workers Compensation 03 Disability 06 Workers Comp* Medicare Set Aside Patient Name HICN Medicare Claim Number This number is on your remittance Claim Amount Refunded Black Lung Federal Public Liability Date of Service Medicare Secondary Payer Provide the following primary insurance information and attach a copy of the primary payer EOB. Insurer Information Policy Information Name Subscriber Name Relation to Patient City Policy Number State Zip Code Group Number Contact Person Related Diagnosis Injury Date if applicable NOTE If specific patient/HICN/claim number information is not provided no appeal rights can be afforded with respect to this refund. Providers/physicians/suppliers and other entities who are submitting a refund under the OIG s Self-Disclosure Protocol are not afforded appeal rights as stated in the signed agreement presented by the OIG* 05/10/2012 http //www. wpsmedicare. com/ Don t miss out on important Medicare news Visit us at http //www. wpsmedicare. com/listserv to sign up for eNews or enter your e-mail address here and we ll sign you up*. From To Indiana Payment Recovery P. O. Box 8811 Marion IL 62959-0910 Provider/Supplier Name Address Michigan City State Zip Code PTAN Tax Identification Number TIN Contact Name Amount of Check Telephone Number Refund Check Check Date Did Medicare Request This Refund Yes No If Yes indicate the Accounts Receivable Number this number is on your letter please include a copy of your letter OIG Reporting Requirements This refund is the result of a Corporate Integrity Program Reason Code for Refund Please check the reason for this refund 01 Working Aged 04 Auto/No Fault 02 ESRD 05 Workers Compensation 03 Disability 06 Workers Comp* Medicare Set Aside Patient Name HICN Medicare Claim Number This number is on your remittance Claim Amount Refunded Black Lung Federal Public Liability Date of Service Medicare Secondary Payer Provide the following primary insurance information and attach a copy of the primary payer EOB. Insurer Information Policy Information Name Subscriber Name Relation to Patient City Policy Number State Zip Code Group Number Contact Person Related Diagnosis Injury Date if applicable NOTE If specific patient/HICN/claim number information is not provided no appeal rights can be afforded with respect to this refund.