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Uniform COVER SHEET

For Health Care Claim Attachments

NOTE: To maximize use of this form, use of Microsoft Word version 2003 or later is recommended

Select appropriate payer/group purchaser from the drop-down list or fill-in the “Other” option

|TO: | |

| |Other fax #: (Type payer/group purchaser name and fax # if not in drop-down list) |

| |Name:       |

| |Fax #:       |

Tab or use your arrow keys to navigate to the next or previous text field.

For specific field directions refer to the

Instructions

|Attachment Control Number: |      |

| | | | |

|Billing Provider ID #: |      |

| | | | |

|Billing Provider Name: |      |

| | | | |

|Patient ID #: |      |

| | | | |

|Patient Name: | | | |

|      |      |      |

|(Last) |(First) |(Middle) |

| | | | |

|Property and Casualty Claim #: |      |

| | | | |

|Attachment Send Date: |      |

| | | | |

|Total Number of Pages: |     |

| | | | |

|Contact Name/Phone #: |      |

|Disclaimer:       |

| |INSTRUCTIONS |

|Attachment Control Number |Create a unique Attachment Control Number* of 50-characters or less |

| |Enter that Attachment Control Number either: |

| |In the paperwork (PWK06) segment in Loop 2300 of the 837 |

| |In the appropriate field on your claim if entered via a direct data entry (DDE) method, like MN–ITS Interactive |

| |or Orbit |

| | |

| |Refer to Minnesota Uniform Companion Guide for the 837, Section 3.2.5 |

| | |

| |*Attachment control numbers are created by each provider using their own numbering scheme and must be unique for |

| |a particular attachment within a billing provider. Unique in this situation means for each PWK06 segment there is|

| |an individual number that must match the attachment cover sheet. You may have multiple cover sheets and multiple |

| |PWK06 segments for the same claim. |

| |Failure to complete this field accurately may result in rejection of the entire claim. |

|Billing Provider ID Number |Enter your NPI, UMPI, or payer assigned legacy ID number. |

| |For Current Version of ANSI 837 Use: |

| |X12: NPI: Loop 2010AA, NM109 |

| |Legacy ID (for atypical providers only): Loop 2010BB, REF02 |

|Billing Provider Name |Enter your billing provider name. |

| |X12: Loop 2010AA, NM103, NM104 and NM105 |

|Patient ID Number |Enter the patient’s unique ID as assigned by the payer/group purchaser. |

| |For Current Version of ANSI 837 Use: |

| |X12: Loop 2010BA, NM109 |

|Patient Name |Enter the patient’s name as reported on the claim. |

|Last |For Current Version of ANSI 837 Use: |

|First |X12: Loop 2010CA, NM103, NM104, and NM105 or Loop 2010BA, NM103, NM104, and NM105. If both are populated within |

|Middle |the claim, use Loop 2010CA, NM103, NM104, and NM105. |

|Property and Casualty Claim|This field is required only if services are related to a Property & Casualty claim. |

|ID Number |X12: Loop 2010CA, REF02 or Loop 2010BA, REF02. |

|Attachment Send Date |Enter the date you will send the attachment and this Cover Sheet in MMDDYY format. |

|Total Number of Pages |Enter the total number of pages of your attachment including the Attachment Cover Sheet |

|Contact Name / Phone Number|Enter the name and phone number of the individual or department in your organization for the payer/group |

| |purchaser to contact in case of fax transmission error |

Return to Attachments

Version: 6-02-12 Revised 08-12-15

Approved by Ops: November 14, 2015

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