Clients submitting attachments for (Non-Worker’s Comp) Commercial, Medicare, Blue Cross/Blue Shield or Medicaid Claims will need to include ACN numbers (Attachment Control Number) on their claims. As per ANSI standards, this information must be received by the payer in the PWK segment of the ANSI claim.
For clients submitting in print image format, this information must be present in box 19 to insure the ACN number is moved, during processing, to the appropriate Loop and Segment on the outbound ANSI claim. ACN numbers not flagged appropriately, with the PWK information in box 19 on the inbound print image claim, may experience delays or denials for claims with unmatchable attachments.
Iowa providers will need to follow payer specific guidelines when sending attachments to Medicaid. See our previously posted alert for more information.
Minnesota providers are bound by state mandate and should follow the guideline set forth by the AUC.
Clients submitting in ANSI format:
Contents of Loop 2300 & Segments PWK01, PWK02, PWK05 & PWK06
Clients submitting in a print image format:
Contents of Box 19 on CMS 1500
Use the following list of qualifiers to populate Box 19 or Loop 2300 PWK:
Report Type Code (PWK01)
77 Support Data for Verification. REFERRAL. Use this code to indicate a completed referral form.
AS Admission Summary
B3 Physician Order
B4 Referral Form
DA Dental Models
DG Diagnostic Report
DS Discharge Summary
EB Explanation of Benefits (Coordination of Benefits or
Medicare Secondary Payer)
NN Nursing Notes
OB Operative Note
OZ Support Data for Claim
PN Physical Therapy Notes
PO Prosthetics or Orthotic Certification
PZ Physical Therapy Certification
RB Radiology Films
RR Radiology Reports
RT Report of Tests and Analysis Report
Report Transmission Code (PWK02)
AA Available on Request at Provider Site
This means that the paperwork is not being sent
with the claim at this time. Instead, it is available to
the payer (or appropriate entity) at their request.
BM By Mail
EL Electronically Only. Use to indicate that attachment is being transmitted
in a separate X12 functional group.
FX By Fax
When sending claims with attachments (non-worker’s comp), please utilize the instructions to avoid delays, lost attachments and/or denials on your claims. If you have questions or feedback, please contact our customer service department at 1-800-688-8087.
ACN (Attachment Control Number) numbers are usually a random number or a number using a payer specified format that is unique for each claim. If you do not know what number to use, whether to create your own number or what format should be used in the creation of the number, please contact that specific payer for details. All attachments will be faxed to the insurance carrier, not Infinedi. If you need to know how long you have to fax or mail your attachment after filing your claim or where to fax the attachments, again, please contact payer for details.