WPS CORRECTED CLAIM FORM (ONE MEMBER AND CORRECTION PER FORM)

THIS FORM CAN ONLY BE USED FOR CORRECTIONS TO PAID OR PARTIALLY PAID SERVICES – IF CLAIM WAS DENIED IN FULL, SUBMIT AS A NEW CLAIM TO WPS

Claims denied in full for reason code ’18’ or ‘DU’, please contact the appropriate WPS Call Center listed below for resolution

PROVIDER NAME: TAX ID: ADDRESS:

PHONE NUMBER:

MEMBER/PARTICIPANT ID: FIRST & LAST NAME: ORIGINAL CLAIM NUMBER: YOU MUST CHECK AND COMPLETE ALL BOXES THAT ARE APPLICABLE AND ATTACH YOUR PROVIDER REMITTANCE ADVICE – IF NOT COMPLETED OR REMITTANCE NOT ATTACHED, THE FORM WILL BE RETURNED:

INCREASE OR DECREASE

BILLED AMOUNT ORIGINAL AMOUNT NEW AMOUNT UNITS BILLED ORIGINAL UNITS NEW UNITS

CHANGE TO : REASON FOR CHANGE: ______

DATE OF SERVICE ORIGINAL DATE NEW DATE AUTHORIZATION ORIGINAL AUTH NEW AUTH CPT/HCPCS/REV ORIGINAL CODE NEW CODE

CLAIM PARTIALLY PAID AND PARTIALLY DENIED WITH REASON CODE ‘NO’ AUTHORIZATION MUST BE UPDATED PRIOR TO SUBMISSION OF CORRECTED CLAIM FORM

CLAIM PARTIALLY PAID AND PARTIALLY DENIED WITH REASON CODE ‘AH’ AUTHORIZATION MUST BE UPDATED PRIOR TO SUBMISSION OF CORRECTED CLAIM FORM

Milwaukee County Dept of Family Care Community Care Connections of Wisconsin ContinuUs C/O WPS Insurance Corp C/O WPS Insurance Corp C/O WPS Insurance Corp PO BOX 7460 PO BOX 7310 PO BOX 8158 Madison, WI 53707-7460 Madison, WI 53707-7310 Madison, WI 53708 - 8158 800-223-6016 800-223-6016 800-223-6016

The Lakeland Care District Bureau of Long Term Support CLTS Waiver C/O WPS Insurance Corp C/O WPS Insurance Corp PO BOX 8631 PO BOX 14517 Madison, WI 53708 - 8631 Madison, WI 53708 – 0517 800-223-6016 877-298-1258