COVID-19 Vaccines or Monoclonal Antibody Infusion Roster Form
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WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
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WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 234-7331
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USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 518-3285
7:00 AM - 5:00 PM CT, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 234-7331
8:00 AM - 5:00 PM ET, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
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WPS GHA
ATTN: Audit Supervisor
P.O. Box 8696
Madison, WI 53708-8696
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WPS GHA
ATTN: Audit Supervisor
1717 W. Broadway
Madison, WI 53713-1834
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ATTN: Audit Supervisor
P.O. Box 14172
Madison, WI 53708-0172
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COVID-19 Vaccines or Monoclonal Antibody Infusion Roster Form
You currently have jurisdiction selected, however this page only applies to these jurisdiction(s): .
Use the attached form for submitting COVID-19 vaccines or monoclonal antibody (mAb) infusions. When submitting a roster claim, you must submit a CMS-1450 (UB-05) claim form along with the completed roster form. Do not submit the roster form alone. See COVID-19 Vaccine and Monoclonal Antibody (mAB) Infusion Billing for Part A Providers for a list of fields that should be completed on the claim form.
Use the attached form for submitting COVID-19 vaccines or monoclonal antibody (mAb) infusions. When submitting a roster claim, you must submit a CMS-1450 (UB-05) claim form along with the completed roster form. Do not submit the roster form alone. See COVID-19 Vaccine and Monoclonal Antibody (mAB) Infusion Billing for Part A Providers for a list of fields that should be completed on the claim form.
Use the attached form for submitting COVID-19 vaccines or monoclonal antibody (mAb) infusions. When submitting your roster claim, you must submit a CMS-1500 (02/12) claim form along with the roster form. Do not submit the roster form alone.
Use the attached form for submitting COVID-19 vaccines or monoclonal antibody (mAb) infusions. When submitting your roster claim, you must submit a CMS-1500 (02/12) claim form along with the roster form. Do not submit the roster form alone.
Please submit separate forms for the COVID-19 vaccines and the monoclonal antibody infusions. Do not submit COVID-19 vaccines and mAB infusions on the same form.
COVID-19 vaccines may be billed for dates of service on and after December 11, 2020.
Monoclonal antibody infusions may be billed for dates of service on and after November 11, 2020.
Only bill the vaccine administration codes to Medicare. Do not include the actual vaccine codes when vaccines are free.
global-tags: J8A,J5A,COVID-19,J8B,Claims Forms,J5B,Vaccines,Forms
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DDE Navigation & Password Reset: (866) 518-3251
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DDE System Access: (866) 518-3295
7:00 am to 4:30 pm CT M-F
EDI: (866) 518-3285
7:00 am to 5:00 pm CT M-F
General Inquiries:
(866) 518-3285
7:00 am to 5:00 pm CT M-F
Claim Status/Patient Eligibility:
(866) 234-7331
24 hours a day, 7 days a week
Claim Corrections:
(866) 580-5980
8:00 am to 5:30 pm ET M-Th
DDE Navigation & Password Reset: (866) 580-5986
8:00 am to 5:30 pm ET M-F
DDE System Access: (866) 518-3295
8:00 am to 5:30 pm ET M-F
EDI: (866) 234-7331
8:00 am to 5:00 pm ET M-F
General Inquiries:
(866) 234-7331
8:00 am to 5:00 pm ET M-F
Claim Status/Patient Eligibility:
(866) 518-3285
24 hours a day, 7 days a week
Claim Corrections/Reopenings:
(866) 518-3285
7:00 am to 5:00 pm CT M-F
EDI: (866) 518-3285
7:00am to 5:00 pm CT M-F
General Inquiries:
(866) 518-3285
7:00 am to 5:00 pm CT M-F
Claim Status/Patient Eligibility:
(866) 234-7331
24 hours a day, 7 days a week
Claim Corrections/Reopenings:
(866) 234-7331
8:00 am to 5:00 pm ET M-F
EDI: (866) 234-7331
8:00 am to 5:00 pm ET M-F
General Inquiries:
(866) 234-7331
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