Submitting worker compensation claim electronically - what are the attachement required to submit

Electronic Bill Attachments


(a) Required reports and/or supporting documentation to support a bill as defined in Complete Bill Section 3.0 shall be submitted in accordance with this section. Unless otherwise agreed by the parties, all attachments to support an electronically submitted bill must either have a header or attached cover sheet that provides the following information:

(1) Claims Administrator - the name shall be the same as populated in the 005010X222, 005010X223, or 005010X224. Loop 2010BB, NM103.

(2) Employer - the name shall be the same as populated in the 005010X222, 005010X223, or 005010X224, Loop 2010BA, NM103.

(3) Unique Attachment Indicator Number - the Unique Attachment Indicator Number shall be the same as populated in the 005010X222, 005010X223, or 005010X224, Loop 2300, PWK Segment: Report Type Code, the Report Transmission Code, Attachment Control Qualifier (AC) and the unique Attachment Control Number. It is the combination of these data elements that will allow a claims administrator to appropriately match the incoming attachment to the electronic medical bill. Refer to the Companion Guide Chapter 2 for information regarding the Unique Attachment Indicator Number Code Sets.

(4) Billing Provider NPI Number – the number must be the same as populated in Loop 2010AA, NM109. If the provider is ineligible for an NPI, then this number is the provider?s atypical billing provider ID. This number must be the same as populated in Loop 2010AA, REF02.

(5) Billing Provider Name.

(6) Bill Transaction Identification Number – This shall be the same number as populated in the ASC 005010X222, 005010X223, or 005010X224 transactions, Loop 2300 Claim Information, CLM01.

(7) Document type – use Report Type codes as set forth in Appendix C of the Companion Guides.

(8) Page Number/Number of Pages the page numbers reported should include the cover sheet.

(9) Contact Name/Phone Number including area code.

(b) All attachments to support an electronically submitted bill shall contain the following information in the body of the attachment or on an attached cover sheet:

(1) Patient?s name
(2) Claims Administrator?s name
(3) Date of Service
(4) Date of Injury
(5) Social Security number (if available)
(6) Claim number (if available)
(7) Unique Attachment Indicator Number
(c) All attachment submissions shall comply with the rules set forth in Section One – 3.0 Complete Bills and Section Three – Security Rules. They shall be submitted according to the protocols specified in the Companion Guide Chapter 8 or other mutually agreed upon methods.

(d) Attachment submission methods:

(1) FAX

(2) Electronic submission – if submitting electronically, the Division strongly recommends using the ASC X12N/005010X210 Additional Information to Support a Health Care Claim or Encounter (275) transaction set. Specifications for this transaction set are found in the Companion Guide Chapter 8. The Division is not mandating the use of this transaction set. Other methods of transmission may be mutually agreed upon by the parties.

(3) E-mail – must be encrypted


(e) Attachment types
(1) Reports
(2) Supporting Documentation
(3) Written Authorization
(4) Misc. (other type of attachment)

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