Provider Responsibility

50.10.2.1 - Provider Responsibility (Rev. 2803, Issued: 10-28-13, Effective: 09-17-13, Implementation: 09-17-13) Providers that wish to utilize the PWK process to submit their additional documentation will be required to use a specially designed cover sheet which will be provided to them by their servicing A/B MACs, or DME MACs. Contact your servicing A/B MACs or DME MACs for details on how/where to obtain the cover sheet. These cover sheets will be required to be completely and accurately filled out or they will be manually returned. It is important to note that the A/B MACs or DME MACs is not required to return your additional documentation along with the cover sheet. In the instance where the coversheet is returned due to inaccurate or incomplete information, the claim will be adjudicated according to the normal CMS business policies and procedures without regard for the additional documentation received. When submitting an electronic claim, the submitter must indicate in the body of the electronic claim their intention to submit additional documentation (at the claim level, line level, or both) along with their claim. This is done by indicating the following in the electronic claim: the PWK elements PWK01 (attachment type), PWK02 (transmission method), PWK05 (the value AC), and PWK06 (a 1-50 byte attachment control number [ACN] of the provider/claim submitter’s choosing). PWK data submitted at the claim level will apply to the whole claim, unless overridden at the detail line level. Line level PWK data will only apply to that particular detail line of the claim. Electronic claims submitted with an improperly formatted PWK segment will be rejected back to the submitter via either an ASC X12 277CA claim acknowledgment or an ASC X12 999 implementation acknowledgment depending on the nature and location of the error. Although the ASC X12 837 claim transaction allows for up to 10 iterations of the PWK at both the claim and line level, only the first iteration of the PWK segment will be utilized for claim adjudication. Additional iterations of the PWK segment beyond one will be stored by the claims processing contractor to which the claim was submitted. Once the electronic claim has been submitted with the PWK, provider/claim submitters are expected to submit their additional documentation as soon as possible. Providers will be required to either fax or mail their additional documentation to the A/B MACs or DME MACs. The only exception will be for those A/B MACs or DME MACs which are part of an approved CMS electronic attachment pilot. In that case, your A/B MACs or DME MACs will notify you of other acceptable methods for submitting your additional documentation. As a rule, the provider/claim submitter is required to provide the additional documentation within 7 calendar days, if utilizing fax, or within 10 calendar days, if utilizing mail. After the 7/10 day waiting period expires, the claim will be adjudicated according to the normal CMS business procedures and policies in place at the time. Documentation submitted late will not be considered for adjudication but will be imaged and sent off for storage as per normal CMS correspondence retention requirements.