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

77

Support Data for Verification

REFERRAL. Use this code to indicate a completed referral form.

AS

Admission Summary

B2

Prescription

B3

Physician Order

B4

Referral Form

CT

Certification

DA

Dental Models

DG

Diagnostic Report

DS

Discharge Summary

EB

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

MT

Models

NN

Nursing Notes

OB

Operative Note

OZ

Support Data for Claim

PN

Physical Therapy Notes

PO

Prosthetics or Orthotic Certification

PZ

Physical Therapy Certification

RB

Radiology Films

RR

Radiology Reports

RT

Report of Tests and Analysis Report

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

This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

BM

By Mail

EL

Electronically Only

Use to indicate that attachment is being transmitted in a separate X12 functional group.

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 = “BM”, “EL”, “EM” or “FX”.

C

ID

1/2

Situational

Code

Name

AC

Attachment Control Number

PWK06

67

Identification Code
Description: Code identifying a party or other code
Industry: Attachment Control Number
Required if PWK02 = “BM”, “EL”, “EM” or “FX”.

C

AN

2/80

Situational

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 there is 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 transmitted 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 segment 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*OB*BM***AC*DMN0012~