Palmetto GBA offers the availability of fax service for electronic submitters. Information sent via fax allows for additional documentation to be provided on claims being sent electronically. Before sending faxed documentation, please be sure that the information sent is necessary to process your claim. Palmetto GBA publishes claim requirements in the Medicare Advisory and in our Local Coverage Determinations when additional documentation is required for a procedure code, modifier or certain circumstance.
Fax Instructions:
- The documentation should be faxed on the same day the electronic claim is submitted or one to two days prior
- The fax cover sheet must accompany each document
- A single document cannot be matched to multiple fax cover sheets
- 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)
- When submitting the claim, the word 'FAX' must be indicated in the documentation record. For ANSI 4010A1 formatted claims, the documentation record is the NTE segment, Note Reference Code ADD, element 02.
Failure to indicate the word 'FAX' may result in an incorrect payment or a denial of a claim. If all fax instructions are not followed, the faxed documentation might not be matched up with the electronic claim.
- To view the EDI Fax Cover Sheet, click on the link below. You can now complete the form online and faxed to our office.
- Questions should be directed to the Ohio & West Virginia EDI Technical Support Center at (866) 308-5438