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Submitting unsolicited paperwork (PWK) segments for electronic claims
Last Modified: 8/17/2023
Location: FL, PR, USVI
Business: Part A, Part B
Under the Health Insurance Portability and Accountability Act (HIPAA), claims for reimbursement by the Medicare Program must be submitted electronically, except where waived, even for claims with attachments.
Submitting medical documentation for your electronic claim can be completed in four easy steps.
1. Create your electronic claim file.
2. Submit your electronic claim file.
3. Complete the
Medicare Fax/Mail/esMD Cover Sheet for Submitting Unsolicited Paperwork (PWK) Segments.
4. Submit the Medicare Fax/Mail/esMD Cover Sheet for Submitting Unsolicited Paperwork (PWK) Segments.
• Only send medical documentation when necessary for the adjudication of procedures or services that are unusual or require such documentation on a pre-payment basis.
• The narrative field (NTE Segment) on the claim is to be utilized in situations where sufficient information for the documentation of a procedure or modifier can be provided without sending the medical records.
• Only fax documentation for one patient per cover sheet.
• Maintain the appropriate medical documentation on file for electronic (and paper) claims.
• Please note, this form is not to be used for sending records in response to Additional Documentation Request (ADR) letters or when submitting a redetermination.
Do not send medical documentation for the following:
• Not otherwise classified procedure code: Enter the description of the code in the description field of the electronic claim (loop 2400 SV101-7).
• Medicare secondary claims: Enter the information from the primary insurer's explanation of benefits in the appropriate fields of the electronic claim.
• Name and dosage of a drug administered: Enter the information in the notes section of the electronic claim (loop 2400 NTE). This is only needed for drugs that do not already have a HCPCS code defined for the name and dosage administered.
Complete all information necessary for the adjudication of your claim.
In the Claim Supplemental Information Segment (PWK) of the electronic claim:
• Select the appropriate Report Type Code for the medical documentation. For information on what codes are needed in the PWK segment, please refer to the 837 implementation guide located on the Washington Publishing Company's website.
• Use the By Fax, By Mail, By X12 275, or by PDF (FX, BM, EL, FT) option for the Attachment Transmission Code
• Enter AC for the Identification Code Qualifier
• Report the Attachment Control Number (ACN) - This number may be assigned by your software or can be any number you chose including the patient account number or other identifying number.
• Only the first iteration of the PWK, at either the claim level and/or line level, will be considered for adjudication.
For information on the completion of this segment in your software, contact your software vendor or refer to the 837 Implementation guide available for purchase on the WPC website listed above.
This segment does not match any box on a paper claim form, as a paper claim would have documents attached to it. If your software looks like a paper claim form, contact your software vendor to discuss what field maps information to the 2300 or 2400 PWK segment of the electronic claim file.
Technically speaking, claim supplemental information section (PWK) is reported as follows:
Data Element |
Segment |
Code / Value |
Attachment Report Type Code |
2300 or 2400 - PWK01 |
Located on the Washington Publishing Company's website. Examples include: AS=Admission Summary DS=Discharge Summary OB=Operative note |
Attachment Transmission Code |
2300 or 2400 - PWK02 |
FX=by Fax BM=by Mail EL=X12 275 through esMD FT=PDF through esMD |
Identification Code Qualifier |
2300 or 2400 - PWK05 |
AC |
Attachment Control Number (ACN) |
2300 or 2400 - PWK06 |
Assigned by software, or number created by provider. Must match number on Medicare Fax/Mail/esMD Cover Sheet for Submitting Unsolicited Paperwork (PWK) Segments. |
Submit the claim using your standard mode of transmission.
• Within seven (7) days AFTER submission, complete and submit the Medicare Fax/Mail/esMD Cover Sheet for Submitting Unsolicited Paperwork (PWK) Segments by clearly writing the:
• Attachment Control Number (ACN). This number may be assigned by your software or can be any number you chose, including the patient account number or other identifying number.
• Internal Control Number (ICN) / Document Control Number (DCN)
• Beneficiary Name
• Medicare ID - This is the patient's Medicare Beneficiary ID Number
• Date of Service
• Total Claim Billed Amount
• Billing Provider's Name
• Contact Information
• National Provider Identification (NPI) Number
• Total Number of Pages including cover sheet
• State Where Services Were Provided (Part B Only)
• Reason Code (Part A Only)
• Failure to submit all items requested will result in documentation being returned and could delay claim processing.
• The ICN / DCN number must be obtained on the 277CA claims acknowledgement report after submitting the electronic claim. The ICN / DCN is in the 2200D REF segment. If you do not normally receive the 277CA or do not know how to retrieve it with your software, please contact your software vendor.
• The Medicare Fax/Mail/esMD Cover Sheet for Submitting Unsolicited Paperwork (PWK) Segments is not to be modified.
• Submitters must send ALL relevant data at the same time for the same claim.
Fax the cover sheet and medical documentation to the appropriate fax number (depending on your locality). Faxes should be sent within seven calendar days of your electronic claim submission. You may fax documentation any time after claim submission, including the same day. Faxing is available 24 hours a day, 7 days a week.
Medicare Part A - Florida |
Medicare Part A - Puerto Rico |
Medicare Part A - U.S. Virgin Islands |
First Coast Service Options, Inc.
P.O. Box 2006
Mechanicsburg, PA 17055-0733 |
First Coast Service Options, Inc.
P.O. Box 2001
Mechanicsburg, PA 17055-0707 |
First Coast Service Options, Inc.
P.O. Box 2001
Mechanicsburg, PA 17055-0707 |
Medicare Part B - Florida |
Medicare Part B - Puerto Rico |
Medicare Part B - U.S. Virgin Islands |
First Coast Service Options, Inc.
P.O. Box 2009
Mechanicsburg, PA 17055-0709 |
First Coast Service Options, Inc.
P.O. Box 2004
Mechanicsburg, PA 17055-0704 |
First Coast Service Options, Inc.
P.O. Box 2004
Mechanicsburg, PA 17055-0704 |
PC-ACE Users can send medical documentation by completing the appropriate sections of the claim form screen and using the Medicare Fax/Mail/esMD Cover Sheet for Submitting Unsolicited Paperwork (PWK) Segments.
• Complete the standard claim information as normal.
• Complete the Claim Supplemental Information (PWK) on the Ext. Pat / Gen (2) Tab or the Line Supplemental Information (PWK) on the Ext. Details 3 Tab.
• Choose the appropriate selection for the Type and Trans field from the drop-down menu.
• Key any number you chose including the patient account number or other identifying number in the Attachment Control Number (ACN) Field. Whatever you key in this field must be put in the Attachment Control Number (ACN) Field on the fax cover sheet.
• Submit the claim and download your 277CA Claims Acknowledgment.
• Locate the ICN on the 277CA for the claim you are sending documentation for.
• Complete the Medicare Fax/Mail/esMD Cover Sheet for Submitting Unsolicited Paperwork (PWK) Segments and fax it with the documentation to First Coast at the number listed on the form.
Source: CR 10124
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
or the Medicare Part B Fax/Mail/esMD Cover Sheet for Submitting Unsolicited Paperwork (PWK) Segments 
