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Printed Date: 9/22/2015
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.).
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.
PWK01 (Attachment Report Type Code)
Use the values indicated in the TR3 to identify the type of attachment.
PWK02 (Attachment Transmission Code)
PWK05 (Identification Code Qualifier)
PWK06 (Attachment Control Number)
Note: Additional documentation should not be submitted for services or circumstances other than those listed in the article Services or Circumstances that Require Additional Documentation.
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Last Updated: 05/02/2019