Instructions for Completing the Medicare PWK Fax Cover Sheet When Submitting Additional Documentation

• When submitting a paper attachment via a Fax, the Claims Processing PWK Fax Cover Sheet (PDF) must be completed. This form can be located under the Claims section of the Forms application on the Palmetto GBA website.
• Send all relevant PWK documentation for the claim at the same time
• Fax number and address is listed on the cover sheet

PWK Fax Cover Sheet
All Fields are required to be completed.

You should only send additional documentation with your claim when Palmetto GBA has specified that this information is required. Please refer to the "Services and Circumstances That Require Additional Documentation" article for a list of procedure codes and modifiers that require additional documentation.

Disclaimer: Documentation received for services or circumstances other than those listed in the article mentioned above (or if specifically requested by Palmetto GBA through the additional documentation request (ADR) process) will not be acknowledged and matched with your claim.

Complete all fields and fax to 803-870-0161 or mail the form to the applicable address/number provided at the bottom of the page. Complete one (1) Medicare Fax / Mail Cover Sheet for each electronic claim for which documentation is being submitted. This form should not be submitted prior to filing the claim.

PWK Data Elements
When you are submitting your additional documentation via the PWK Fax Cover Sheet, the following PWK data elements must be completed.

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 created and 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
• ACN submitted on the claim must match the ACN entered on the PWK coversheet/form