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.
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.
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.