<p> WPS CORRECTED CLAIM FORM (ONE MEMBER AND CORRECTION PER FORM)</p><p>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</p><p>Claims denied in full for reason code ’18’ or ‘DU’, please contact the appropriate WPS Call Center listed below for resolution</p><p>PROVIDER NAME: TAX ID: ADDRESS: </p><p>PHONE NUMBER: </p><p>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:</p><p>INCREASE OR DECREASE</p><p>BILLED AMOUNT ORIGINAL AMOUNT NEW AMOUNT UNITS BILLED ORIGINAL UNITS NEW UNITS </p><p>CHANGE TO : REASON FOR CHANGE: ______</p><p>DATE OF SERVICE ORIGINAL DATE NEW DATE AUTHORIZATION ORIGINAL AUTH NEW AUTH CPT/HCPCS/REV ORIGINAL CODE NEW CODE </p><p>CLAIM PARTIALLY PAID AND PARTIALLY DENIED WITH REASON CODE ‘NO’ AUTHORIZATION MUST BE UPDATED PRIOR TO SUBMISSION OF CORRECTED CLAIM FORM</p><p>CLAIM PARTIALLY PAID AND PARTIALLY DENIED WITH REASON CODE ‘AH’ AUTHORIZATION MUST BE UPDATED PRIOR TO SUBMISSION OF CORRECTED CLAIM FORM</p><p>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</p><p>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</p>