Wps Medicare Part B Kansas Fax Form
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1B02
WPS MEDICARE PART B
KANSAS FAX
(Please indicate which type of request you are submitting.)
REDETERMINATION REQUEST
Appeal of Overpayment (please attach overpayment letter)
REOPENING REQUEST
To: Medicare Appeals Department
Fax Number: 608-223-7547
# of pages _____ (including cover sheet)
ALL REQUESTED INFORMATION ON THIS FAX FORM MUST BE COMPLETED.
INCOMPLETE FORMS MAY BE RETURNED TO THE SENDER.
Provider Information
Date _____________
Contact Name __________________________
Contact Phone Number___________________
Claim Information
Claim ICN* in question __________________________
*ONE REQUEST FORM IS REQUIRED FOR EACH ICN. THE ICN IS LOCATED ON YOUR
REMITTANCE NOTICE.
IMPORTANT NOTE:
THIS FAX FORM ALONE DOES NOT QUALIFY AS A VALID REDETERMINATION REQUEST OR
REOPENING REQUEST.
YOU MUST ATTACH A VALID REQUEST TO THIS FAX FORM.
REDETERMINATION AND REOPENING REQUEST FORMS ARE LOCATED ON THE WPS
MEDICARE WEBSITE AT
ALL REQUESTS WILL BE PROCESSED IN ACCORDANCE WITH INTERNET ONLY MANUAL
(IOM) 100-04 CHAPTER 29 AND 34.
THIS MESSAGE IS INTENDED ONLY FOR THE USE OF THE INDIVIDUAL OR ENTITY TO WHICH IT
IS ADDRESSED AND MAY CONTAIN INFORMATION THAT IS CONFIDENTIAL AND/OR PRIVILEGED.
IF THE READER OF THIS MESSAGE IS NOT THE INTENDED RECIPIENT, YOU ARE HEREBY
NOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION OR COPYING OF THIS COMMUNICATION IS
STRICTLY PROHIBITED. IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR, PLEASE
NOTIFY US IMMEDIATELY BY CALLING TOLL FREE AT 1 (866) 518-3285 AND CONFIRM
DESTRUCTION OF THE INFORMATION. THANK YOU.
11/12/2014
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