Get Palmetto GBA Claims Processing PWK Fax Cover Sheet 2019
Being submitted. This form should not be submitted prior to ling the claim. Instructions for Completing the Medicare PWK Fax Cover Sheet When Submitting Additional Documentation ACN: (Exactly as entered in the PWK loop on the claim) ICN: Bene ciary Last Name: Bene ciary First Name: Medicare ID: Date of Service Start: Date of Service End: Total Claim Billed Amount: / / / / Billing Providers Name Billing Provider Phone Number: ( NPI: ) - Total Number of Documentation Pages:.
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