Medicare Part B Form PDF Details

Navigating the world of Medicare can feel like an overwhelming and confusing task. And while all beneficiaries have their own individual needs, there are some fundamentals that apply to everyone. This includes understanding and completing the Medicare Part B form - a crucial document for enrolled participants in Original Medicare (Parts A & B). In this post, we'll take a look at what the Part B form is, why it matters, when you need to complete it, how you can do so online or by mail with other corresponding forms, and more. Whether you're just enrolling in or renewing your coverage through Medicare Parts A & B - or if someone in your family is doing so – let's get started!

QuestionAnswer
Form NameMedicare Part B Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesMarion, MCO, Indiana, wps medicare part b non msp refund form

Form Preview Example

WPS Medicare Part B Non-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

Michigan

Provider/Supplier Name

 

 

 

WPS Medicare Part B

WPS Medicare Part B

 

 

 

 

 

Payment Recovery

Payment Recovery

 

 

 

 

 

P.O. Box 8811

P.O. Box 5511

Address

 

 

 

 

 

 

Marion, IL 62959-0910

Marion, IL 62959-0945

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State, Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PTAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tax Identification Number (TIN)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Name

 

 

Telephone Number

 

 

 

Amount of Check:

 

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 This refund is the result of an OIG Self-Disclosure Program

Yes Yes

No No

Reason Code for Refund…Please check the reason for this refund:

 

 

 

01

Corrected Date of Service

06

Billing Error

 

11

Patient in SNF

02

Duplicate

07

Insufficient Documentation

 

12

Hospice

03

Corrected CPT Code

08

Patient Enrolled in HMO/MCO

13

Veterans’ Administration

04

Not our Patient(s)

09

Services Not Rendered

 

14

Other, please specify:

05

Mod. Add/Remove

10

Medical Necessity

 

 

 

 

Patient Name:

 

 

 

HICN:

 

Date of Service:

 

Medicare Claim Number (This number is on your remittance):

Claim Amount Refunded:

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.

NOTE: If specific patient/HICN/claim number information is not available for all claims due to statistical sampling, please indicate the methodology and formula used to determine amount and reason for overpayment:

05/10/2012http://www.wpsmedicare.com/1

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How to Edit Medicare Part B Form Online for Free

You'll be able to work with PTAN easily by using our PDF editor online. FormsPal development team is always working to enhance the tool and ensure it is much faster for users with its multiple functions. Uncover an ceaselessly progressive experience today - check out and uncover new possibilities as you go! To begin your journey, take these simple steps:

Step 1: First, open the editor by clicking the "Get Form Button" in the top section of this page.

Step 2: This editor provides the ability to modify PDF files in a variety of ways. Change it with your own text, adjust what's already in the file, and include a signature - all manageable within minutes!

Concentrate while filling out this form. Make sure every single blank is filled in accurately.

1. Begin completing your PTAN with a number of essential fields. Gather all the required information and ensure absolutely nothing is neglected!

Stage number 1 for submitting OIG

2. Soon after this part is completed, go to enter the relevant information in all these: From ProviderSupplier Name Address, Patient in SNF Hospice Veterans, Insufficient Documentation, Date of Service, HICN, Yes Yes, and No No.

Yes Yes, Patient in SNF Hospice Veterans, and HICN inside OIG

3. Completing Dont miss out on important, and httpwwwwpsmedicarecom is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

httpwwwwpsmedicarecom, httpwwwwpsmedicarecom, and Dont miss out on important in OIG

People who work with this document frequently get some points incorrect while filling out httpwwwwpsmedicarecom in this area. You need to read again everything you type in right here.

Step 3: Before finalizing the document, make certain that blanks have been filled out as intended. The moment you verify that it is correct, press “Done." Right after getting a7-day free trial account here, you'll be able to download PTAN or send it through email at once. The PDF file will also be at your disposal from your personal account menu with your edits. FormsPal is invested in the confidentiality of our users; we make sure that all personal data entered into our tool remains protected.

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