How to fill/completing the PWK fax/mail coversheet

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.

PWK issues

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.

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]), 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 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 coversheet.

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

How to submit document during first claim submission - detailed review - PWK segment

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 October 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

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 number, 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 ten calendar waiting days to be mailed. The seven and ten 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 ten day waiting period.

Faxination numbers

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 coversheet includes the appropriate First Coast return mailing address and faxination number, based on the provider's selection.