Last Modified: 11/5/2021
Location: FL, PR, USVI
Business: Part A, Part B
First Coast sometimes requires providers to submit additional documentation for services to adjudicate the claim. If you know your service will result in an additional documentation request (ADR) from us, PWK is an easy and proactive option for you to submit this documentation with your initial electronic claim.
PWK (Paperwork) is a segment within the 2300/2400 loop of the 837 Professional and Institutional electronic transactions and allows you to indicate on a Part A or Part B electronic claim that you’re submitting additional documentation via mail or fax (PWK 02 segment, BM [by mail] and FX [by fax] qualifier).
When a claim with a PWK indicator is selected for review, we'll wait seven calendar days (or 10 calendar days, if documentation is mailed) for the arrival of the paper documentation. At the end of the seven (or 10) calendar days, if paperwork is received, analysis of the claim will be completed. If paperwork is not received in the designated timeframe, you may receive an ADR request letter or claim denial. If the claim is denied, information will be included on a future remittance advice.
Providers and trading partners can use our interactive fax/mail/esMD coversheet
to submit the unsolicited additional documentation. We offer secure faxination numbers if you prefer to fax the additional documentation. Just complete the required data elements and print a hardcopy of the form to mail or fax with your documentation.
When submitting PWK claims and documentation, follow these steps:
Submit electronic claim with the appropriate PWK indicator
• Only send medical documentation when necessary for the adjudication of procedures/services that are unusual or require such documentation on a pre-payment basis.
• Apply the correct PWK indicator(s) to the claim (claim level/line level) (Loop ID 2300 or 2400 PWK)
• Select the appropriate Report Type Code for the medical documentation (PWK 01)
• For information on what codes are needed in the PWK segment, please refer to the 837 implementation guide
• Examples include:
• Use the By Fax or By Mail (FX or BM) option for the Attachment Transmission Code (PWK 02)
• Enter AC for the Identification Code Qualifier (PWK 05)
• Report the Attachment Control Number (ACN) (PWK 06)
• 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 PWK, at either the claim level or line level, will be considered for adjudication.
• Submit the electronic claim and download your 277CA (claims acknowledgment) to locate the document control number (DCN) or internal control number (ICN) for the claim you are submitting the documentation.
Complete Medicare Part A or B fax/mail/esMD coversheet
• Do not fill out a PWK unsolicited documentation fax/mail/esMD coversheet if you receive an ADR letter. Please follow the instructions within the ADR letter instead.
• Fully complete the coversheet to ensure proper receipt and processing of your documentation. Incomplete coversheets may be rejected.
• Complete coversheet electronically, prior to printing. This will assist in ensuring legibility and processing.
• Note: Only one coversheet will be accepted for each submitted claim.
• All sections of the form are required to be completed with valid information to ensure the paperwork documentation is appended to the correct pending claim in our system
• ACN (submitted in the PWK 06 segment)
• DCN (Part A) or ICN (Part B)
• You can locate the DCN or ICN on the 277CA for the claim you are submitting the documentation.
• Beneficiary's Medicare Beneficiary Identifier (MBI)
• Billing provider's name and NPI (national provider identifier)
• Contact name, contact phone number and complete return mailing address with any additional information needed
Immediately fax or mail PWK coversheet and documentation to First Coast
• Only submit documentation for one patient per coversheet.
• Fax numbers and mailing addresses are located directly on coversheet.
• Transmission of PWK documentation must be consistent with PWK 02 transmission code submitted on claim, as well as be received within the specified timeframe below.
• Include all supporting documentation.
• Note: If any part of documentation appears to be missing (or received past the allotted timeframe), submitted documentation will not be used for claim processing.
• If documentation is needed, we will instead suspend the electronic claim and request all supporting documentation through the normal ADR process, regardless if partial information was previously submitted using PWK.
• 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 submission timeframes
Once you submit a claim with PWK indicator(s) that has been identified for a potential ADR, the claims processing system will suspend the claim to a holding location. 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.
PWK documentation may not be submitted prior to submission of a claim.
First Coast encourages providers to send documentation immediately after claim submission as these submission timeframes account for providers mailing time and processing time. If the documentation is identified beyond the deadline, the claim will process as if the documentation had not been received. Once a claim has been released for normal processing, MACs are not required to search for the delayed documentation.
Note: Claims submitted with a PWK segment that would not otherwise suspend for review and/or require additional development, will process routinely and not be held for the seven- or 10-day waiting period.
Any Part A or Part B provider who submits claims to First Coast that may require additional documentation to be reviewed prior to adjudicating their claim can benefit from use of PWK.
First Coast has provided designated faxination lines to expedite receipt of the PWK coversheets/attachments, depending on the provider’s line of business and location (Part A or Part B; Florida, Puerto Rico, or the U.S. Virgin Islands.)
Each fax/mail/esMD coversheet
includes the appropriate First Coast return mailing address and faxination number, based on the provider's selection.
Here are important items to verify before faxing or mailing your coversheet:
• Verify you have indicated the ACN (submitted in the PWK 06 segment), DCN or ICN, the beneficiary's Medicare ID, billing provider's name and NPI on the PWK fax/mail/esMD coversheet.
• 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 documentation without the completed fax/mail/esMD coversheet.
• Do not use the PWK coversheet for any reason other than the PWK process.
• Do not modify the fax/mail/esMD coversheet.
In some 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 common situations.
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, we’ll send an ADR letter and providers will need to respond to the letter.
If you suspect documentation will be requested, submit the initial claim with the proper indicators in the PWK loop.
PWK coversheet is received with related documentation attached and a copy of our ADR letter. 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.
1) If you suspect documentation will be requested, submit the initial claim with the proper indicators in the PWK loop.
2) If you receive an ADR, respond with appropriate documentation per the ADR letter instructions. Do not submit requested documentation on a PWK coversheet.
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 adjust or correct your claim. Appeal requests submitted via the PWK fax/mail process will not be acknowledged.
If your claim has been denied or you need to adjust or correct your claim, please use the appropriate level of the appeals process.
In all these instances, since the PWK fax/mail coversheet or claim is not being submitted correctly or with 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.
Additional information on the PWK segment is available in the X12 Version 5010 837I and 837P Companion Guides.
Source: CR 10397
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.