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The form collects provider and contact details, including fax number, phone number, NPI, and provider number (PTAN), and requires completion of every field with accurate, legible typed or handwritten entries. It instructs faxing the additional documentation on the same day or up to two days before the electronic claim, marking the record with “FAX,” limiting transmissions to 100 pages, and requiring the cover sheet with each document. 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Entries must be accurate and typed or written legibly.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"When should the additional documentation be faxed relative to an electronic claim?",{"text":113,"@type":109},"Fax the documentation on the same day or up to two days prior to the electronic claim submission, and ensure the word “FAX” is indicated in the documentation record of the electronic claim submission.",{"name":115,"@type":106,"acceptedAnswer":116},"What are the consequences of not using the fax cover sheet correctly?",{"text":117,"@type":109},"Failure to use the form correctly may result in incorrect payment or denial of the claim.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},275116,1790219961,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":20,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},962085564549,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","PLEASE DO NOT USE STAPLES FOR ANY DOCUMENTATION  \nAdditional Documentation Fax Cover Sheet  \nALL fields are REQUIRED.  \nProvider Information  \nProvider Name:  \nContact Name:  \nFax Number:  \n(  \n\n|  | ) |  |\n| --- | --- | --- |\n\n-  \nPhone Number:  \n(  \n\n|  | ) |  |\n| --- | --- | --- |\n\n-  \nNational Provider Identifier (NPI):  \nProvider Number (PTAN):  \nINSTRUCTIONS:  \nProviders who submit claims electronically can fax additional required documentation (e.g. Operative reports, discharge summaries etc. ) . You may refer to the Medicare Advisory to determine when additional documentation is required.  \nPlease complete this form in its entirety and include it with your additional documentation. Do not use this fax cover sheet for any other purpose. Please ensure you complete the actions listed below.  \n The documentation must be faxed on the same day or up to two days prior to the electronic claim submission. The word ‘FAX’must be indicated in the documentation record of the electronic claim submission.  \n This fax cover sheet must accompany each document. Each field of the fax cover sheet form must be completed and must be accurate. The information should be typed or written legibly.  \n Please limit your fax to a maximum of 100 pages, including cover sheets.  \nFailure to use this form correctly may result in incorrect payment or denial of your claim.  \nSpecial Instructions:  \nCONFIDENTIALITY NOTICE  \nThe document being transmitted contains private, privileged, and confidential information belonging to the sender and intended for use by the addressee only. If this transmission is received by anyone other than the addressee, please advise the sender immediately at 1-888-355-9165 so that we can arrange for the return of the documents. In such circumstances, you are advised that you may not review, disclose, copy, distribute, or take any other action in connection with the documents transmitted.  \nCL-RRB-B-4040  \nCL-RRB-B-4040-2  \nRevised 3/2018  \nPlease send this form and all additional documentation via  \nFax: (803) 264-9842","cbCainQaCfRFNvDa","https://ap.wps.com/l/cbCainQaCfRFNvDa","pdf",524228,"English","# Provider Information\n## Required Fields\n# Submission Instructions\n## Timing and Marking Requirements\n## Page Limit and Completion Standard\n# Confidentiality Notice","[{\"question\":\"What information must be completed on the fax cover sheet?\",\"answer\":\"All fields are required, including provider name, contact name, fax number, phone number, National Provider Identifier (NPI), and provider number (PTAN). Entries must be accurate and typed or written legibly.\"},{\"question\":\"When should the additional documentation be faxed relative to an electronic claim?\",\"answer\":\"Fax the documentation on the same day or up to two days prior to the electronic claim submission, and ensure the word “FAX” is indicated in the documentation record of the electronic claim submission.\"},{\"question\":\"What are the consequences of not using the fax cover sheet correctly?\",\"answer\":\"Failure to use the form correctly may result in incorrect payment or denial of the claim.\"}]","Additional Documentation Fax Cover Sheet - All Fields Required - Revised 3/2018 | PDF",1789485058]