Electronic Claims Attachments

Claim attachments are supplemental documents providing additional medical information to the claims processor that cannot be accommodated within the claim format. Common attachments are Certificates of Medical Necessity (CMNs), discharge summaries and operative reports. They are sent to the carrier/intermediary with the original claim or in response to a request from a carrier/intermediary.

On September 23, 2005 a Notice of Proposed Rule Making (NPRM) was published in the Federal Register announcing proposed standards for six types of electronic claims attachments and the standard to be used by health benefit plans to request an attachment and identify the type of information that is needed. A copy of the implementation guide proposed in that NPRM as the national standard for these attachments is available without cost at the Washington Publishing company web site. A link is provided below.

There is a link to the NPRM available through a separate CMS web page. Instructions and the deadline for submission of NPRM comments and actions to be taken by CMS once that comment closes is included on that page. A link to that webpage is also provided below.

PWK allows documentation to be submitted with an initial claim
Effective October 1, 2012, First Coast Service Options Inc. (First Coast) implemented the PWK (paperwork) segment of the X12N version 5010. PWK allows for voluntary submission of supporting documentation with a 5010 version electronic claim.
PWK is a segment within the 2300/2400 Loop of the 837 Professional and Institutional electronic transactions that provides the link between electronic claims and additional documentation. PWK allows providers to submit electronic claims that require additional documentation and, through the dedicated PWK process, have the documentation imaged to be available during the claims adjudication. Eliminating the need for costly development and allowing providers and Medicare contractors to utilize efficient, cost-effective Electronic Data Interchange or EDI technology will create a significant cost savings.
Although PWK ultimately will allow electronic submission of additional documentation, the current implementation only allows for submission of additional documentation via mail and fax (PWK 02 segment, BM [by mail] and FX [by fax] qualifier, respectively).
First Coast has made available a fax/mail coversheet that providers or trading partners shall use to submit the unsolicited additional documentation. The First Coast fax/mail coversheet is an interactive form posted to our website. Providers or trading partners may complete required data elements and are then able to print a hardcopy of the form to mail or fax with their documentation. Modifications to the fax/mail coversheet are not permitted. Separate forms are provided for Part A and B for Florida, Puerto Rico, and the U.S. Virgin Islands. First Coast has also provided secure faxination numbers for those providers or trading partners who elect to fax the additional documentation.
PWK Fax/mail coversheets
Click on the appropriate link in the breakout at the top right of this page to access the coversheet.
First Coast is requiring the following section of the form to be completed with valid information to ensure the paperwork documentation is appended to the pending claim in our system: ACN (Attachment Control Number (submitted in the PWK06 segment)), DCN (document control number [Part A]), ICN (internal control number [Part B]), the beneficiary’s health insurance claim number (HICN)/Medicare ID, Billing provider’s name and NPI (national provider identifier).
First Coast will return PWK coversheets with missing or inaccurate data. The coversheet will be returned based on how it was received (fax or mail).
• Note: First Coast will not return any paperwork documentation that accompanies a rejected PWK coversheet; nor will the documentation be used for adjudication of the claim.
PWK documentation may not be submitted prior to submission of a claim. Submitters must send all relevant PWK data at the same time for the same claim. Thus, if the claim was submitted with multiple PWK iterations, all PWK data for the claim must be submitted together under one coversheet.
If the PWK segment is completed and additional documentation is needed for adjudication, First Coast will allow seven calendar “waiting” days (from the claim date of receipt) for the paperwork documentation to be faxed or 10 calendar waiting days to be mailed. The seven- and 10-day waiting periods apply to claims for both Part A and Part B.
If the PWK data is not received within the waiting timeframe and additional documentation is needed, a development request will be sent. If documentation is received after the timeframe has elapsed, the documentation will not be used for adjudication of the claim. Thus, the paperwork will need to then accompany our request for additional documentation to prevent possible claim denials.
Claims submitted with a PWK segment, that would not otherwise suspend for review and/or require additional development, will process routinely and will not be held for the seven or 10-day waiting period