Part B Medicare Secondary Payer (MSP) General Inquiry Form This form is to be used by providers to submit general inquiries to the Medicare Payment Recovery department. Do not use this form to identify an overpayment, submit a refund or inquire about eligibility. The Primary Insurance Explanation of Benefits (EOB) and/or Letter of Exhaust should be included with the inquiry. Verify the MSP Information is accurate by checking C-SNAP or the Integrated Voice Response (IVR) system. If the MSP record is not accurate, the beneficiary should contact the Benefits Coordination & Recovery Center (BCRC) to have the file updated. Select the reason for your inquiry: Benefits Exhausted Incorrect Primary Insurance Allowed, Paid and/or OTAF Amount Other - Please provide explanation in the “Reason For Inquiry” space below Select the state your inquiry involves: Iowa Kansas Missouri Nebraska Provider/Supplier Name National Provider Identifier (NPI) Provider Transaction Access Number (PTAN) Tax Identification Number (TIN) Last 5 Digits Address Telephone Number City, State, Zip Code Contact Person’s Name Patient’s Name Date of Service Medicare Number Date of Birth Claim Number (ICN) Check/EFT Number Reason For Inquiry Fax Completed Inquiry to (608) 223-7550, or mail to: Iowa Kansas Missouri WPS Medicare Part B Payment Recovery P.O. Box 8550 Madison, WI 53708-8550 11/25/2014 WPS Medicare Part B Payment Recovery P.O. Box 7238 Madison, WI 53707-7238 WPS Medicare Part B Payment Recovery P.O. Box 14260 Madison, WI 53708-0260 http://www.wpsmedicare.com/index.shtml Nebraska WPS Medicare Part B Payment Recovery P.O. Box 8667 Madison, WI 53708-8667 Page 1 of 1
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