CMS Pub. 100-04, ch. 24, § 50.10.2.2

A/B MACs and DME MACs will be required to establish dedicated fax lines and Post

Office boxes for provider/claim submitters to utilize for providing the additional

documentation. A/B MACs and DME MACs will provide the education and outreach

support to provider/claim submitters on how to utilize the PWK process.

The A/B MACs and DME MACs shall provide the coversheet to the provider/claim

submitter in whatever manner they feel provides the most effective and efficient method

for providing the cover sheet. If the coversheet is not completely and accurately filled

out, the A/B MACs and DME MACs shall return the coversheet to its originator. A/B

MACs and DME MACs shall indicate that the cover sheet is being returned for

incomplete/inaccurate completion and the documentation is not being taken into

consideration for the purpose of claims adjudication. The A/B MACs and DME MACs

are free to choose the method of returning the cover sheet which they feel best suits their

business operation. It is important to note that the A/B MACs and DME MACs are not

required to return the additional documentation along with the cover sheet. The A/B

MACs and DME MACs are to follow their current correspondence retention

requirements and processes regarding the controlling and storage of the additional

documentation (whether the documentation is utilized for claims processing assessment

or not). If the provider/claim submitter cannot be identified by the A/B MACs and DME

MACs thus making it impossible to return the cover sheet, the documentation will be

imaged and sent off for storage as per normal CMS correspondence retention

requirements. 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.

Additional documentation received by A/B MACs and DME MACs via the PWK process

will be imaged and made available for view and/or retrieval by claims examiners/medical

review staff. A/B MACs and DME MACs staff adjudicating claims will only review

PWK data when the claim encounters an edit/audit requiring additional documentation.

The presence of the PWK indicator within the shared system will alert contractor staff

that there is additional documentation which potentially may be used to adjudicate the

claim. It is important to note that the simple presence of the PWK on a claim will not

cause the claim to suspend.

When A/B MACs and DME MACs staff encounters an edit or an audit within the shared

system that could be affected by additional documentation, they will first look to see if a

PWK was submitted on the claim. If there is a PWK present, they will retrieve the

appropriate additional documentation from their imaging system and review it. If the

additional documentation contains the needed information, the A/B MACs and DME

MACs will adjudicate the claim accordingly and flag the claim as dirty. If the additional

documentation does not contain the needed information, the claim will then be handled

according to the normal CMS business procedures and policies in place at the time.

Regardless of whether or not the PWK additional documentation is utilized in

adjudicating the claim, the waiting days will not count against the contractor’s claims

processing timeliness (CPT).