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Paperwork (PWK) Segment for X12N Version 5010

Overview of PWK
The PWK segment of the X12N version 5010 will be effective beginning October 1, 2012.  The PWK segment provides the “linkage” between electronic claims and additional documentation, which is needed for claims adjudication.  Currently, the PWK segment only allows for submission of additional documentation via mail or FAX. 

The PWK process involves imaging technology, known as optical character recognition (OCR), and allows providers and CGS a cost effective means to submit, image, store and retrieve additional claims documentation. 

The PWK process is different from the electronic submission of medical documentation (esMD).  With PWK, the provider indicates, when submitting their electronic claim, that they will be sending medical documentation.  This occurs prior to the claim going through the medical review selection process, so an Additional Development Request (ADR) has not yet been generated.  With esMD, an ADR has been generated, and the documentation submitted is in response to an ADR. 

The PWK Process
Step 1: A provider wishing to submit medical documentation via PWK must include an Attachment Report Type Code on their electronic claim in PWK segment Loop 2300 (claim level) or Loop 2400 (line level).  For home health and hospice providers, enter the following:

  • Attachment Report Type Code = PWK 02; and
  • BM (documentation sent via mail) or FX (documentation sent via FAX)

Step 2: A PWK cover sheetPDFmust be completed, and submitted on top of the accompanying documentation.   If the form has missing or inaccurate information, it will be rejected, and returned to the provider.  Documentation submitted with a rejected cover sheet will not be returned.  The FAX number and mailing address for sending your documentation are listed on the PWK cover sheet. 

Step 3: When a claim is submitted with the PWK segment, and the claim meets edit criteria, CGS will allow:

  • Seven calendar “waiting” days (from the claim’s receipt date) for additional information to be submitted via FAX; or
  • Ten calendar “waiting” days (from the claim’s receipt date) for additional information to be submitted via mail.

Note: If the claim does not meet edit criteria, CGS will not hold the claim for the 7- or 10-day waiting period, and the claim will process as usual.  However, the documentation will still be received and imaged by CGS for any future needs.

PWK is completely voluntary.  The documentation submitted through the PWK process will only be reviewed if your claim meets one of the current edit criteria.  Otherwise, the documentation will not be used to process your claim.  If your claim meets the edit criteria, and your claim did not include the PWK indicator, it will go through the normal ADR process, and move to status/location S B6001.

Additional PWK Resources
MM7041 – “Implementation of the PWK (Paperwork) Segment for X12N Version 5010” at PDF

MM7306 – “Modifications to the Implementation of the Paperwork (PWK) Segment for X12N Version 5010” at PDF

Posted:  10.08.12

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