PWK

Claim Supplemental Information

Pos: 155	Max: 10
Detail - Optional
Loop: 2300	Elements: 4

Ref

Id

Element Name

Req

Type

Min/Max

Usage

PWK01

755

Report Type Code
Description: Code indicating the title or contents of a document, report or supporting item
Industry: Attachment Report Type Code
NSF Reference: EA0-41.0

M

ID

2/2

Required

Code

Name

B4

Referral Form

DA

Dental Models

DG

Diagnostic Report

EB

Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)

OB

Operative Note

OZ

Support Data for Claim

P6

Periodontal Charts

RB

Radiology Films

RR

Radiology Reports

PWK02

756

Report Transmission Code
Description: Code defining timing, transmission method or format by which reports are to be sent
Industry: Attachment Transmission Code
NSF Reference: EA0-40.0

O

ID

1/2

Required

Code

Name

AA

Available on Request at Provider Site

Paperwork is available on request at the provider’s site. This means the paperwork is not being sent with the claim at this time. Rather, it is available to the payer (or appropriate entity) at their request.

BM

By Mail

EL

Electronically Only

EM

E-Mail

FX

By Fax

PWK05

66

Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification Code (67)
Required if PWK02 = EM, EL, BM or FX.

C

ID

1/2

Recommended

Code

Name

AC

Attachment Control Number

PWK06

67

Identification Code
Description: Code identifying a party or other code
Industry: Attachment Control Number
The developers of this implementation guide recommend that the sender identify the attachment with a unique attachment control number so that the recipient can match the attachment to the claim.
Required if PWK02 = EM, EL BM, or FX.

C

AN

2/80

Recommended

1.

P0506 - If either PWK05,PWK06 is present, then all are required

1.

PWK05 and PWK06 may be used to identify the addressee by a code number.

2.

PWK07 may be used to indicate special information to be shown on the specified report.

3.

PWK08 may be used to indicate action pertaining to a report.

Notes:

1. The PWK segment is required if the provider will be sending paper documentation supporting this claim. The PWK segment should not be used if the information related to the claim is being sent within the 837 ST-SE envelope.
2. The PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmittted in another functional group (e.g., 275) rather than by paper. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be carried in the TRN of the electronic attachment.
3. The PWK can be used to identify paperwork that is being held at the provider’s office and is available upon request by the payer (or appropriate entity), but that is not being sent with the claim. Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.

Example:

PWK*DA*BM***AC*DMN0012~