New…Improved… Streamlined… WPS Medicare (Part B) Appeals Redetermination Form
To ensure your appeal has all the required information when submitted, we highly recommend you begin using the NEW WPS Medicare Part B Redetermination Request Form today. Completing the form aids in the efficient processing of the request.
WPS Medicare will continue to process complete Redetermination requests, whether you use the CMS form 20027 or the WPS form. If you choose to request a redetermination WITHOUT a form, the following information MUST be included:
- Beneficiary name
- Medicare Health Insurance Claim Number (HICN)
- Date(s) of service for which initial determination was issued
- Which item(s), if any, and/or service(s) are at issue in the appeal
- Name and signature of the party or representative of the party
- Reason(s) you disagree with the initial claim(s) determination
Incomplete or missing information will delay or dismiss your redetermination.
The new WPS Medicare Redetermination Form is available on the WPS Medicare Website: http://www.wpsmedicare.com/part_b/selfservice/forms.shtml
Page Last Updated: Wednesday, 30-Dec-2009 10:48:24 CST
