WPS CORRECTED CLAIM FORM TIP SHEET

(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

**DO NOT SUBMIT A CORRECTED CLAIM IF THE

ORIGINAL CLAIM WAS DENIED IN FULL**

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

FIELD NAME / INFORMATION TO INCLUDE
PROVIDER NAME / BILLING PROVIDER NAME
TAX ID: / EIN OR SSN (9 DIGIT) NUMBER
ADDRESS: / PROVIDER BILLING ADDRESS
MEMBER/PARTICIPANT ID: / 9 DIGIT MEMBER NUMER
FIRST & LAST NAME: / MEMBER FIRST AND LAST NAME
ORIGINAL CLAIM NUMBER: / CLAIM NUMBER OF ORIGINAL CLAIM THAT WPS
PROCESSED FROM THE PRA/EOB SENT FROM WPS

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 Please check the appropriate box DO NOT SEND THE DIFFERENCE

IN THESE FIELDS-SEND THE

NEW TOTAL

BILLED AMOUNT / ORIGINAL AMOUNT / The total charge billed on the original claim to WPS / NEW AMOUNT / The new total charge that should have been billed to WPS
UNITS BILLED / ORIGINAL UNITS / The total units billed on the original claim to WPS / NEW UNITS / The new total units that should have been billed to WPS

CHANGE TO : REASON FOR CHANGE: ______

DATE OF SERVICE / ORIGINAL DATE / The original date of service on the claim billed to WPS / NEW DATE / The new date of service that should have been billed to WPS
AUTHORIZATION / ORIGINAL AUTH / The original authorization number on the claim billed to WPS / NEW AUTH / The new authorization number that the claim should have been billed with
CPT/HCPCS/REV / ORIGINAL CODE / The original service code on the claim billed to WPS / NEW CODE / The service code that the claim should have been billed with

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 / Southwest Family Care Alliance / NorthernBridges
C/O WPS Insurance Corp / C/O WPS Insurance Corp / C/O WPS Insurance Corp / C/O WPS Insurance Corp
PO BOX 7460 / PO BOX 7310 / PO BOX 8158 / PO BOX 8607
Madison, WI 53707-7460 / Madison, WI 53707-7310 / Madison, WI 53708 - 8158 / Madison, WI 53707-8607
800-223-6016 / 866-331-3919 / 877-206-1447 / 888-915-2498
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
888-915-2499 / 877-298-1258

IF YOU HAVE QUESTIONS ABOUT HOW TO FILL OUT THIS FORM-PLEASE CONTACT YOUR APPROPRIATE

CALL CENTER NUMBER LISTED ON THE BOTTOM OF THE CORRECTED CLAIM FORM