Electronic Claims and Additional Documentation

Palmetto GBA offers the availability of a fax service or eServices Portal for electronic submitters to submit additional documentation (e.g., operative reports, discharge summaries, progress notes, etc.).

• Additional documentation for electronic claims may be submitted via fax or eServices Portal
• You should only send additional documentation with your claim when Palmetto GBA has specified that this information is required. When additional documentation is required for a procedure code, modifier or certain circumstances, Palmetto GBA publishes the requirements in the Medicare Advisory and in Local Coverage Determinations (LCDs).

Fax Instructions

• The documentation may be faxed on the same day the electronic claim is submitted or one to two days prior
• A fax cover sheet must accompany each document
• The cover sheet must be typed or written legibly and completed accurately
• Be sure to specify the patient's name, Medicare Health Insurance Claim Number and all other required information
• Please limit your fax to a maximum of 100 pages, including cover sheets

Use the Additional Documentation Fax Cover Sheet form in the Forms section on the Part B website and fax to (803) 699–3588.

When submitting the claim, the word “fax” must be indicated in the documentation record of the electronic claim. Failure to indicate the word "fax" may result in an incorrect payment or a denial of a claim.

If all fax instruction procedures are not followed, the faxed documentation may not be matched up with the electronic claim.

eService Portal Instructions
When required, additional documentation should be submitted using the eServices portal and your claim must include the necessary information (electronic claim PWK segments or Item 19 on the CMS-1500 claim form) to alert Palmetto GBA that you have submitted required documentation.

When submitting your additional documentation via eServices the following PWK data elements must be completed on your electronic claim.

Loop 2300
PWK01 (Attachment Report Type Code)
Use the values indicated in the TR3 to identify the type of attachment.

Examples:

• M1 (medical record attachment)
• OD (orders and treatments document)
• P5 (patient medical history document)
• PY (physician’s report)

PWK02 (Attachment Transmission Code)

• Indicates a code identifying how the attachment will be sent
• PWK02 = BM (mail) FX (fax) or EL (electronically)

PWK05 (Identification Code Qualifier)

• Required when PWK02 = BM, FX or EL
• PWK05= AC

PWK06 (Attachment Control Number)

• A value assigned by the provider/software vendor to uniquely identify the attachment
• Must be 2–50 characters
• Can be all numeric, all alphabetical, and/or a combination

Note: Additional documentation should not be submitted for services or circumstances other than those listed in the article Services and Circumstances that Require Additional Documentation.