Medicare Part B Form PDF Details

Navigating the complexities of Medicare refunds can feel daunting, especially when it comes to understanding how to properly use the Medicare Part B form. This particular form, used for processing non-Medicare Secondary Payer (MSP) refunds, serves as a critical tool for healthcare providers and suppliers in Indiana and Michigan. By properly completing this form and including the necessary documents such as refund checks and a copy of the remittance notice, providers can ensure a smooth refund process with WPS Medicare Part B Payment Recovery services. Each patient requires a separate form, emphasizing the importance of detailed record-keeping and accuracy. Additionally, the form asks for comprehensive details including the provider or supplier’s name, tax identification number, contact information, and specifics about the refund itself like the check number, date, and reason for the refund. With several potential reasons for issuing a refund — from billing errors to duplicate payments — it’s vital to specify the cause clearly. Moreover, the form addresses the Office of Inspector General (OIG) reporting requirements, which is an essential consideration for providers engaged in the Corporate Integrity Program or those that have self-disclosed under the OIG’s protocols. This highlights the intersection of financial integrity and compliance within the healthcare sector. Understanding each element of the Medicare Part B Non-MSP Refund Form is key to maintaining both compliance and operational efficiency in healthcare practices.

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

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Stage number 1 for submitting OIG

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

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

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