DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13470A (10/08)
STATE OF WISCONSIN HFS 106.03(1), Wis. Admin. Code
CLAIM FORM ATTACHMENT COVER PAGE COMPLETION INSTRUCTIONS
Paper attachments that correspond to electronic claim transactions must be submitted with the Claim Form Attachment Cover Page, F-13470. The use of this form is mandatory when submitting paper attachments with electronic claim submissions; any other format of the Claim Form Attachment Cover Page will be returned to the provider unprocessed. The Attachment Control Number (ACN) selected by the provider must be indicated on the cover page in order to match the electronic claim with the paper attachment. ForwardHealth will hold an electronic claim transaction or a paper attachment(s) for up to 30 calendar days to find a match. If a match cannot be made within 30 days, the claim will be denied. When such a claim is denied, both the paper attachment(s) and the electronic claim will need to be resubmitted. Providers are required to send paper attachments relating to electronic claim transactions to the following address: ForwardHealth Claims and Adjustments 6406 Bridge Rd Madison WI 53784-0002 Instructions: Type or print clearly. The ACN entered on this form must match the ACN entered on the electronic claim submission. Date Transmitted: Enter the date the electronic claim was submitted, if known. Attachment Control Number (ACN): Enter the number selected by the provider that matches the ACN submitted on the electronic claim. The ACN can be any alphanumeric entry between two and 80 characters in length. Provider Number: Enter the provider number of the billing provider. Member Identification Number: Enter the member ID of the member for whom the claim was submitted.