First Coast Service Options’ (First
Coast’s) claims department is receiving a high volume of invalid or unnecessary
PWK (5010 paperwork segment) fax/mail coversheets. If a coversheet is received
containing inaccurate, incomplete, or invalid information, the coversheet will
be either faxed or mailed back to the originating source, but without the
documentation. Coversheets returned in this manner should not be resent; instead,
the provider should await an additional documentation request (ADR) before
submitting the documentation again to First Coast.


In other cases, the coversheets and
additional documentation are not able to be appropriately attached to a claim
due to several reasons. The following list has been developed to assist you in
avoiding these situations.
1. PWK coversheet is received,
completed accurately with documentation, but the claim was submitted without
the indicators in the PWK loop.
• This will not allow us to assign
the documentation in the system to the appropriate claim. If the claim requires
documentation, an ADR letter will be sent and providers will need to respond to
the letter.
2. PWK coversheet is received with
the related documentation attached and a copy of our additional documentation
request (ADR) letter. Again, the PWK loop indicators are not on the claim.
• There are two issues here: 1)
without the PWK loop completed, the claim will not suspend to look for any
anticipated documentation. Most importantly 2) the claim has already suspended
for additional documentation; therefore, providers only need to respond to the
ADR letter with appropriate documentation.
3. PWK coversheet is received with a
request for an appeal/redetermination in the information box.
• The PWK process may only be used
on initial claim submission. PWK cannot be used to bypass the standard appeals
process. Please use the appropriate level of the appeals process if your claim
has been denied or you need to make adjustments/corrections. Appeal requests
submitted via the PWK fax/mail process will not be acknowledged.
4. In all of these instances, since
the PWK fax/mail coversheet and/or claim is not being submitted correctly or
with the correct information, the supporting documentation submitted to us is
not being utilized to adjudicate the claim. Also, since in most cases this is
outside of the standards for PWK, providers affected by these scenarios will
not receive a response concerning the outcome or lack thereof.
5. Our internal claims area is being
negatively impacted as well as our electronic storage capacity is being
overwhelmed by unneeded, unusable documentation. Providers affected by this
will more than likely never receive any indication of the negative impacts this
is having on their claims.


Here are some items to verify before
faxing or mailing your form:

• Verify you have indicated the 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 number, billing
provider’s name and NPI (national provider identifier) on the fax/mail

• Include an address to mail the
coversheet to, in case we are unable to fax it back to the originating number.

• Fax users: ensure to send your PWK
fax coversheet and documentation to the appropriate locality fax line. Example:
claims for providers in Puerto Rico should be faxed to the Puerto Rico fax
line; claims for Florida providers to the Florida fax line; etc. If a
coversheet is received into the incorrect faxination account, we will be unable
to locate the claim.

• Do not send in documentation
without the completed fax/mail coversheet.

• Do not
use the PWK coversheet for any reason other than the PWK process.