Mailing Paper Attachments for Electronic Claims
Providers must follow certain procedures when submitting paper attachments associated with an electronic claim. For 837 electronic claim transactions (submitted through File Exchange), providers must submit all attachments by mail, following the process described in this section.
Note: When submitting claims via the Portal, providers are strongly encouraged to upload attachments electronically, as described in the Attachments section in the institutional, professional, and dental claim-submission instructions in Sections 2, 3, and 4 of this module. However, in cases where uploading to Portal is not possible, such as when the file size is too large, the IHCP also accepts attachments submitted by mail for Portal claims. Providers should indicate in the Portal claim that attachments are being submitted by mail, and then follow the instructions in this section to prepare and send the attachments.
The following steps describe how to submit paper attachments to electronic claims by mail:
- Assign a unique attachment control number (ACN) to each paper attachment to be submitted, and write the ACN on each page of each attachment.
– An ACN can be up to 30 characters in length, and can be numbers, letters, or a combination of letters and numbers.
– After an ACN has been used, it cannot be used again, even if the same claim is resubmitted at a later date.
– Documents cannot be shared between claims.
– The ACN must be written on the top of the document. If an attachment has more than one page, the ACN must be written on each page of the document.
– Write in only blue or black ink on the attachments.
Indicate on the 837 transaction or the Portal claim, as follows, that additional documentation will be submitted:
– Enter an attachment report transmission code. This required code indicates whether an electronic claim has documentation to support the billed services. This code defines the timing and transmission method or format of reports and how they are sent. The IHCP accepts paper attachments only by mail. This attachment transmission code is BM (by mail).
➢ 837 transaction: Enter BM in loop 2300, segment PWK02, data element 756.
➢ Portal: Select BM – By Mail in the Transmission Method field of the Attachments panel.
– Enter the unique ACN for the attachment. The ACN entered must match the ACN on the Claims Attachment Cover Sheet and on each page of the attachment sent by mail.
➢ 837 transaction: Enter the ACN in loop 2300, segment PWK, data element 67.
➢ Portal: Enter the ACN in the Control # field of the Attachments panel.
– Enter an attachment report type code. This code indicates the type of attachment the provider is sending to the IHCP to support the electronic claim. The code indicates the title or contents of a document, report, or supporting item. For a complete listing of attachment report type codes, see the appropriate 837 claim transaction IG, or see Table 1 in this document.
➢ 837 transaction: Enter the attachment report type code in loop 2300, segment PWK01, data element 755
Complete an IHCP Claims Attachment Cover Sheet for each set of attachments associated with a specific claim. The Claims Attachment Cover Sheet is available on the Forms page at in.gov/medicaid/providers. Include the following information on the Claims Attachment Cover Sheet:
– Billing provider’s name, service location address, and ZIP Code+4
– Billing provider’s National Provider Identifier (NPI) or IHCP Provider ID
➢ Only atypical providers may use the IHCP Provider ID.
➢ See the Provider Enrollment module for more information about NPIs and Provider IDs.
– Dates of service on the claim
– IHCP Member ID (also known as RID)
– ACN for each attachment associated with the claim (The provider may submit a maximum of 20 ACNs with each cover sheet.)
– Number of pages associated with each attachment (not including the cover page
CLAIM FORM ATTACHMENT COVER PAGECOMPLETION INSTRUCTIONS – Forward Health insurance
Paper attachments that correspond to electronic claim transactions must be submitted with the Claim Form Attachment Cover Page, F-13470. The use of this form is mandatory when submitting paper attachments with electronic claim submissions; any other format of the Claim Form Attachment Cover Page will be returned to the provider unprocessed.
The Attachment Control Number (ACN) selected by the provider must be indicated on the cover page in order to match the electronic claim with the paper attachment.
ForwardHealth will hold an electronic claim transaction or a paper attachment(s) for up to 30 calendar days to find a match. If a match cannot be made within 30 days, the claim will be denied. When such a claim is denied, both the paper attachment(s) and the electronic claim will need to be resubmitted.
Providers are required to send paper attachments relating to electronic claim transactions to the following address:
ForwardHealth
Claims and Adjustments
313 Blettner Blvd
Madison WI 53784
Instructions: Type or print clearly. The ACN entered on this form must match the ACN entered on the electronic claim submission.
Date Transmitted: Enter the date the electronic claim was submitted, if known.
Attachment Control Number (ACN): Enter the number selected by the provider that matches the ACN submitted on the electronic claim. The ACN can be any alphanumeric entry between two and 80 characters in length.
Provider Number: Enter the provider number of the billing provider.
Member Identification Number: Enter the member ID of the member for whom the claim was submitted.
Other methods for Additional Information Exchanged Today.
During the claims adjudication process or during utilization review the payer may determine that additional information is required, resulting in a request to the provider. The payer may also communicate a list of procedures or services that would require additional information for the claim or prior authorization allowing the provider to submit without waiting for a request. The process may be automated based on predefined rules or the request for information is systematically generated and sent to the provider.
The attachment information may be submitted using multiple methods based on payer requirements. Examples of methods used today are:
Paper – the payer sends a letter to the provider and the provider returns a copy of the letter with the information requested by mail, fax, or uploaded to an electronic web portal.
•Telephone – the payer calls the provider and asks the questions and the provider communicates the information while on the call.
•Website- the payer contacts the provider and points to a URL for a document that would require completion by the provider.
•Secure email– the payer and provider have established a workflow to allow for the request and response to be handled through a secured email exchange.
•Fax– the payer faxes a form to the provider to complete and fax back. (The payer must have the provider fax number on file or obtain it before using this method).•Internet –trading partners use Secure FTP or other secured protocols
•Claim Denial – Payer denies payment for a claim, indicating the need for additional information as requested. This would trigger an appeal or resubmission of the claim with the additional information.
