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Last Modified: 11/5/2021 Location: FL, PR, USVI Business: Part A, Part B

Avoid issues completing the PWK fax/mail/esMD coversheet

First Coast encourages you to avoid submitting invalid or unnecessary PWK (5010 paperwork segment) fax/mail/esMD coversheets. When a coversheet is received containing inaccurate, incomplete, or invalid information, it will be faxed or mailed back to the originating source, but without the documentation. Coversheets returned in this manner should not be resent. Instead, you should await an additional documentation request (ADR) letter before submitting the documentation to us.

PWK issues

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.

Issue
Problem
Resolve
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 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.

Reminders

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]) or ICN (internal control number [Part B]), the beneficiary's Medicare ID, billing provider's name and NPI on the 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 in 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.
Click here for more detailed information on the PWK option
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.