Bluecross Pwk Fax Cover Sheet

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PWK Fax Cover Sheet
BlueCross BlueShield of Tennessee
1 Cameron Hill Circle
Chattanooga, TN 37402
This form will allow you to submit documentation related to your electronic claims. We will match this documenta-
tion to your electronic claim and utilize for claims processing and payment. To ensure we match the documents to
your electronic claim for processing; this form should be submitted no later than the day of claims submission.
This form is NOT for EOB’s, Remits, or Claims that have already been paid.
This form is NOT for primary claim payment information (which should be submitted with your EDI claim).
Instructions:
Complete ALL required fields in CAPITAL Letters.
Note: BCBST will only match on the first iteration of PWK06 (ACN) from the ANSI 837 data.
This is in accordance with CMS Guidelines.
Ensure your first iteration at claim or line level matches the PWK06 (ACN) that is provided below.
Only include your 1-50 byte attachment control number (ACN) reported in the PWK06 segment of the claim
that these records pertain to.
Use this form as the fax coversheet for your documentation.
Complete ONE (1) Fax Cover Sheet for each electronic claim for which documentation is being submitted.
FAX PWK Fax Cover Sheet with documentation to 423-591-9481
REQUIRED Information:
Attachment Control Number (ACN) [PWK06]:*
Member Number (Include Alpha Prefix):
Member First Name:
Member Last Name:
Date of Service (DOS) From:**
Total Claim Charge:
Tax Identification Number (TIN):
Billing NPI:
Total Number of Pages (Include Cover Sheet):
Document Type: MEDREC
Additional Information:
BCBST Provider Number:
Provider Contact Name:
Provider Contact Number:
This facsimile contains confidential information intended only for the use of the specific individual or entity named above. If you or your employer
are not the intended recipient of this facsimile (or an agent responsible for delivering it to the intended recipient), you are hereby notified that, any
unauthorized distribution or copying of this facsimile for the information contained in it, is strictly prohibited. If you have received this facsimile in
error, please immediately notify the person named above by telephone. Thank You.
*Do Not Include Special Characters such as $, &, etc.
**Format to be MMDDYY
BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association
16PED7781 (7/16)

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