HELPFUL HINTS FOR FORM CMS-855:
COMPLETING YOUR EFT APPLICATION
Part II-Provider or Supplier Information.
- Ensure that the Tax ID, Medicare ID and NPI numbers are listed correctly.
- If you are submitting applications for subunits please fill out a separate CMS-588 for each unit as well as the main facility.
- Include a voided check or deposit slip that matches the information given on the application.
- If you are unable to supply a voided negotiable item please include a letter from the financial institution on their letterhead that cites the provider name, account, and routing number that matches the information listed on your application.
- Cite the person who should be contacted in the case of an error on the application or if additional information is needed.
- This person does not need to be the signor.
- Please include a fax number and an email address.
- The blank line must contain either "Wisconsin Physicians Service" or "WPS" only. We cannot accept any other entry or the line left blank.
- The EFT authorization form must be signed and dated by the same Authorized Representative or a Delegated Official named on the CMS-855 Medicare enrollment application which WPS has on file.
CMS mandated as of April 2006, that all new Medicare enrollees must receive payments electronically through EFT. All existing providers are required to begin EFT when submitting changes to their existing enrollment information.
Once providers are enrolled in EFT, the EFT agreement cannot be terminated and providers cannot request to receive paper checks.
Providers can update or change bank information as necessary.
To avoid delays in processing your application, please consider the following:
- Ensure that all information is legible and accurate.
- If you have not revalidated with an 855A application within the last five years you will be required to do so at this time. If you are unsure if a revalidation will be needed or would like more information you may contact Provider Enrollment at 866-734-9444 and request to speak with the Provider Enrollment department.
- Mail your application with the original signature (no facsimile or photocopied signatures can be accepted) to WPS at the address listed below:
|
Regular Delivery Wisconsin Physicians Service Attention: Finance PO Box 1602 Omaha NE 68101 |
Overnight Delivery Wisconsin Physicians Service Attention: Finance 3333 Farnam Street Omaha NE 68131 |
If questions remain that were not addressed above or on the instruction page of the application, you may reach the WPS Part A Finance Department directly at 866-734-1522. Analysts are available to assist you between the hours of 7:30 am and 4:00 pm CT, Monday through Friday.
Page Last Updated: Monday, 23-Nov-2009 13:20:18 CST
