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  • Cl-jm-b-4050 2015

Get Cl-jm-b-4050 2015-2025

Insurance Claim (HIC) Number: Fax Number: ( ) Claim Date(s) of Service Phone Number: - ( ) - From: To: / Provider (NPI): / / CPT/HCPCS Code: / CPT/HCPCS Code: Provider Number (PTAN): INSTRUCTIONS: Providers who submit claims electronically may fax etc.). Refer to the Medicare Advisory and required. l required Local Coverage y and include it with your Please complete this form in its s listed below. purpose. Please ensure you complete the n (e.g. o e reports, discharge summar.

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Complete all fields and fax to 803-870-0161 or mail the form to the applicable address/number provided at the bottom of the page. Complete one (1) Medicare Fax / Mail Cover Sheet for each electronic claim for which documentation is being submitted. This form should not be submitted prior to filing the claim.

Complete all fields and fax to 877- 439-5479 or mail the form to the applicable address/number provided at the bottom of the page. Complete ONE (1) Medicare Fax / Mail Cover Sheet for each electronic claim for which documentation is being submitted.

PWK was developed to allow providers to submit additional documentation to support services billed with or at time of claim submission. indicators are submitted directly on the electronic claim. They are designed to notify that additional documentation will be submitted to support the billing/services of the claims.

For Standard requests, complete this form and FAX to 1-877-808-9368.

The Administrative Simplification Compliance Act (ASCA) requires that Medicare claims be sent electronically unless certain exceptions are met. Providers meeting an ASCA exception may send their claims to Medicare on a paper claim form. (For more information regarding ASCA exceptions, refer to Chapter 24.)

ACN: The Attachment Control Number (ACN) is used to identify the documentation. This is submitted on the claim. The ACN is user defined, with a maximum field length of 50.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232