Medicare Part A/B 5010: Electronic Claim Documentation Submission Guide

Navigating the complexities of medical claim submissions requires precise attention to detail, especially when it comes to supporting documentation. This comprehensive guide will walk you through the process of submitting medical documentation for Medicare Part A/B electronic claims, with a focus on utilizing the Claim Supplemental Information (PWK) segment. While the Health Insurance Portability and Accountability Act (HIPAA) mandated electronic claim submission years ago, efficient methods for attaching supplementary medical records remain crucial for timely adjudication.

This post primarily outlines the process for out-of-band attachments (fax or mail) as supported by Medicare Administrative Contractors (MACs) like Novitas Solutions. While these methods are still valid, it’s important to note that more integrated electronic attachment solutions, such as the X12 275 transaction or specific MAC portals, are also available and may be preferred. Always consult your specific MAC’s guidelines for the most current and preferred methods for electronic claims documentation requirements and the Medicare 5010 electronic claim attachment process.

Table of Contents

1. Understanding Electronic Claim Documentation Requirements
2. What is the PWK Segment?
3. When is Documentation Necessary for Claim Adjudication?
4. Step-by-Step Guide to Submitting Documentation via Fax or Mail
5. Preparing and Using Official Cover Sheets
6. Completing the PWK Segment for Medical Billing
7. Locating the ICN/DCN on the 277CA Claims Acknowledgment Report
8. Faxing Medical Records to Medicare for Electronic Claims
9. Mailing Medical Records for Electronic Claims
10. Important Tips for Timely Adjudication
11. Glossary of Key Terms

Understanding Electronic Claim Documentation Requirements

Maintaining appropriate medical documentation on file is essential for all electronic and paper claims. The Claim Supplemental Information (PWK) segment within the electronic claim is utilized whenever paper documentation, such as medical records, is sent separately to support an electronic claim. This process ensures that the supplementary information can be accurately linked to the corresponding electronic submission, aiding in the Medicare 5010 electronic claim attachment process.

What is the PWK Segment?

The PWK segment (Claim Supplemental Information) is a crucial component of electronic claims that indicates when additional documentation is being sent out-of-band (via fax or mail) to support a claim. It contains specific codes that tell the payer what type of documentation is coming and how it’s being transmitted. Understanding the PWK segment guidelines for medical billing is vital for successful claim adjudication.

When is Documentation Necessary for Claim Adjudication?

Only send medical documentation when it is explicitly required for the adjudication of procedures or services. This typically applies to items that are unusual, require pre-payment review, or fall under specific medical policies. Sending unnecessary documentation can delay processing.

Examples of situations where additional documentation might be required include:

• Procedures or services that are not commonly performed or are outside of typical medical necessity parameters.
• Services requiring prior authorization where the authorization details need further support.
• High-cost procedures or services that frequently undergo medical review.
• Items or services that exceed frequency limitations set by Medicare.

Billers can find detailed requirements in official Medicare publications, such as National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) specific to your MAC, and the Medicare Claims Processing Manual. The narrative field on the electronic claim should be used when sufficient information can be provided without sending full medical records. However, if the narrative is insufficient, additional documentation must be submitted.

Step-by-Step Guide to Submitting Documentation via Fax or Mail

When sending an electronic claim that requires an attachment via out-of-band methods, follow these detailed steps to ensure proper submission and linking:

Preparing and Using Official Cover Sheets

To ensure accurate processing, you must complete the appropriate Medicare Fax/Mail Cover Sheet. These forms are specific to your MAC. For Novitas Solutions, these include the Medicare Part A Fax/Mail Cover Sheet or the Medicare Part B Fax/Mail Cover Sheet.

• Complete all requested information in capital letters.
• Avoid writing too close to the edge of the boxes.
• Do not modify the cover sheets.
• Only fax documentation for one patient per cover sheet.
• Clearly write the following information on the cover sheet: Attachment Control Number, Internal Control Number (ICN/DCN), Patient Name, Health Insurance Claim (HIC) Number, Date of Service, Total Claim Billed Amount, National Provider Identification (NPI) Number, Contact Information, and State Where Services Were Provided. Failure to submit all requested items will result in documentation being returned and could delay claim processing.

Always verify and obtain the most current cover sheets directly from your Medicare Administrative Contractor’s (MAC) website.

Completing the PWK Segment for Medical Billing

The PWK segment of your electronic claim must accurately reflect the documentation you are sending. This is a critical step in the PWK segment guidelines for medical billing.

In the Claim Supplemental Information Segment (PWK) of the electronic claim, ensure you:

• Select the appropriate Report Type Code (PWK01): This code identifies the type of medical documentation being submitted. For comprehensive information and a list of valid codes, refer to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 24, Section 30.7. Common Report Type Codes include:
  • OZ: Support Data for Claim
  • AD: Admission Summary
  • CT: Certification
  • DG: Diagnostic Report
  • HK: Health Care Claim Status
  • IR: Information for Review
  • P4: Pathology Report
• Use the correct Attachment Transmission Code (PWK02): This code indicates how the documentation is being sent. Use ‘BM’ for By Mail or ‘FX’ for By Fax.
• Enter ‘AC’ for the Identification Code Qualifier (PWK05): This specifies that the following number is an Attachment Control Number.
• Report the Attachment Control Number (PWK06): This number links your physical documentation to the electronic claim. It may be assigned by your billing software or can be any unique number you choose, such as the patient account number or another identifying number.

Technically Speaking, Claim Supplemental Information (PWK) is reported as follows:

 Data Element                Segment
 Attachment Report Type Code   2300 or 2400 – PWK01
 Attachment Transmission Code  2300 or 2400 – PWK02
 Identification Code Qualifier 2300 or 2400 – PWK05
 Attachment Control Number     2300 or 2400 – PWK06 

Note: Only the first iteration of the PWK segment, at either the claim level and/or line level, will be considered for adjudication. Submitters must send ALL relevant PWK data at the same time for the same claim.

Locating the ICN/DCN on the 277CA Claims Acknowledgment Report

After submitting your electronic claim, it’s crucial to locate the Internal Control Number (ICN) or Document Control Number (DCN) on your 277CA Claims Acknowledgment Report. This number is essential for linking your submitted documentation to the specific electronic claim.

Step-by-step instructions:

1. Access the 277CA Claims Acknowledgment Report generated after your electronic claim submission.
2. Navigate to the 2200D REF segment within the report.
3. The ICN/DCN will be clearly identified within this segment.

This unique identifier must be included on your cover sheet when faxing medical records to Medicare for electronic claims or mailing them, ensuring that the documentation is correctly associated with the claim.

Faxing Medical Records to Medicare for Electronic Claims

For Novitas Solutions, faxing your medical documentation is strongly recommended for efficiency.

• Fax the completed cover sheet and all pertinent medical documentation to the designated number. For Novitas Solutions, the current fax number for documentation for electronic claims is (877) 439-5479. Always verify the most current fax number on your MAC’s official website.
• You may fax documentation any time after claim submission, including the same day.
• Faxing services are typically available 24 hours a day, 7 days a week.
• Faxes should be sent within seven calendar days of your electronic claim submission.

Mailing Medical Records for Electronic Claims

If you are unable to fax your documentation, you may mail it. This option is typically recommended as an alternative.

• Mail the appropriate Medicare Part A Fax/Mail Cover Sheet or Medicare Part B Fax/Mail Cover Sheet (Novitas Solutions specific) and all pertinent medical documentation.
• Mailing should occur within ten calendar days of your electronic claim submission.
• Always confirm the correct mailing address for documentation submission directly on your Medicare Administrative Contractor’s (MAC) website, as addresses can vary and are subject to change.

Important Tips for Timely Adjudication

• Always maintain complete and accurate medical documentation on file for all claims.
• Utilize the narrative field on the electronic claim for minor clarifications that do not require full medical records.
• Ensure that all information on the cover sheet is accurate and complete to prevent delays.
• Only send documentation when truly necessary to avoid overwhelming payers and slowing down processing.
• Be mindful of submission deadlines: fax within seven days, mail within ten days of electronic claim submission.

Glossary of Key Terms

• 277CA: The Health Care Claim Acknowledgment transaction, which is an electronic report from the payer confirming receipt and basic acceptance/rejection of claims.
• 5010: The version of the HIPAA electronic transaction standards (e.g., for claims, eligibility) that replaced version 4010/4010A1, implemented to accommodate ICD-10 and other requirements.
• HIPAA: Health Insurance Portability and Accountability Act, a federal law that sets standards for protected health information.
• HIC: Health Insurance Claim Number, a unique identifier previously used for Medicare beneficiaries. Now largely replaced by the MBI (Medicare Beneficiary Identifier).
• ICN/DCN: Internal Control Number / Document Control Number, a unique identifier assigned by the payer to an electronic claim, used to link supplemental documentation.
• MAC: Medicare Administrative Contractor, a private healthcare insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B medical claims.
• NCDs: National Coverage Determinations, national medical policies developed by CMS that describe the circumstances under which specific medical services, procedures, or technologies are covered by Medicare.
• NPI: National Provider Identifier, a unique 10-digit identification number issued to health care providers in the United States by CMS.
• PWK: Claim Supplemental Information segment, used in electronic claims to indicate that additional documentation is being sent out-of-band (via fax or mail).