Completing The HIPAA Attachment Cover Sheet

Completing The HIPAA Attachment Cover Sheet (NJ Medicaid Provider Instructions)

With the implementation of HIPAA electronic data interchanges in the 837 5010 format these claims may now initially be submitted electronically with the required attachments following in the mail. Find the instructions for completing the HIPAA Attachment Cover Sheet below.

  • Complete all necessary Loops and Segments for the electronic claim including Loop 2300; PWK01=OZ, PWK02=BM (BY MAIL), PWK06=Patient Account Number (from Loop 2300; CLM01)
  • Complete and mail the HIPAA Attachment Cover Sheet along with all associated attachments.
    • NJ Medicaid Provider ID: Enter the Provider’s provider number as assigned by DXC Technology.
    • Current Date: Enter the date completing the HIPAA Attachment Cover Sheet in MMDDCCYY format.
    • Provider Name and Address: Enter the Provider’s name and service address.
    • Control Number (ICN): Enter the unique 15-digit Internal Control Number (ICN) as assigned to each claim received by DXC Technology. A range of ICN control numbers may only be entered for claims containing consecutive lines for the Attachment Codes below indicated with an * . This option is not available for claims that require manual pricing. Enter the beginning ICN in the Beginning ICN field and the last ICN in the Ending ICN field.
    • Medicaid Beneficiary ID: Enter the Medicaid Beneficiary ID exactly as it appears on the Eligibility Identification Card.
    • Date of Service: Enter the date or dates the service was provided to the beneficiary.
    • Patient Account Number: Enter the unique Patient Account Number as was submitted electronically.
    • Attachment Code: Check the appropriate box indicating the attachment code and type of documentation to be accompanied by the form. A maximum of three code boxes can be checked.

In the ATTACHMENT CODE section check the appropriate box indicating the attachment code and type of documentation to be accompanied by the form. A maximum of three code boxes can be checked.

To learn more about HIPAA EDI and become a certified  EDI Professional please visit our course schedule page.

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