Appeal Fax Initiative

How to Submit Your Appeal Request by Fax

Submission of your request by fax reduces the amount of time for your redetermination or reopening request to be received by the WPS Medicare Appeals staff. The fax request is received by WPS Medicare as an electronic image. The fax process eliminates possible delays caused by sorting and imaging of hard copy receipts. In addition, the fax confirmation generated by your fax machine provides you with confirmation that WPS Medicare received your request timely.

To submit reopening or redetermination requests by fax you must use the appropriate fax form for your state. The fax forms are located on our website at http://www.wpsmedicare.com/j5macpartb/forms/. To avoid potential problems with your redetermination and reopening request make sure each field is filled in completely on the form. Do not indicate services that need to be reviewed by highlighting the document. Incomplete forms may be returned to the sender.

Please note:

  • Be sure to use the Appeal Fax Number for your state.
  • You must use a different fax number AND form if you are submitting a response to an initial claim development request. Please see the Note below.
  • Each claim or Internal Control Number (ICN) requires a separate form. The ICN is located on the remittance notice.
  • Submitting a fax form alone does not qualify as a valid redetermination or reopening request. The request must also include a Redetermination or Reopening Request form.
  • The fax form and the redetermination and reopening request forms are located on the WPS Medicare website at http://www.wpsmedicare.com/j5macpartb/forms/
  • Requests will be processed according to the date of receipt. All valid redetermination and reopening requests will be processed in accordance with Internet Only Manual (IOM) 100-04 Chapters 29 and 34.

NOTE: The Part B Appeal fax forms and phone numbers are distinct from the fax forms and phone numbers for Claims Development Resolution. Only submit appeal (redetermination or reopening) requests to the Appeal Fax Numbers. See table below for appropriate phone numbers.

State Appeals Fax Form Claims Development Resolution Fax Form
Iowa (608) 223-7541 (608) 223-7542
Kansas (608) 223-7547 (608) 223-7548
Missouri (608) 223-7545 (608) 223-7546
Nebraska 608-223-7543 (608) 223-7544

Page Last Updated: Wednesday, 06-Jul-2011 10:45:47 CDT