The Attachment Control Form (ACF) allows providers to include supporting documentation with their Computer Media Claims (CMC). Attachments can be faxed to Medi-Cal by using the ACF as a cover sheet. The ACF contains an Attachment Control Number (ACN) that must be entered in the appropriate ASC X12N 837 v.4010A1 Paperwork (PWK) Segments. The ACN then links the attachment to its respective electronic claim.

Each fax must be sent separately and include one ACF followed by the corresponding pages of the attachment. The fax number is 1-866-438-9377.

The following are examples of claims submitted through CMC with separate attachments:

• Claims that require an Explanation of Medicare Benefits, Medicare Remittance Notice or Remittance Advice (Medicare status codes 1-7 and 9).
• Claims that include denials from other health coverage carriers such as CHAMPUS, Kaiser, Ross Loos or prepaid health plans.
• Claims billing HCPCS or CPT-4 codes where the price is not listed with Medi-Cal.
• The submitter is unable to include the pricing information for the ASC X12N 837 v.4101A1 Note (NTE) Segment.
• Claims requiring sterilization or hysterectomy consent forms.

Attachment Claim Forms are pre-imprinted with ACNs and may be obtained by calling the Telephone Service Center (TSC) at 1-800-541-5555.

Providers can review additional information and a sample of the ACF in the 837 Billing Instructions section of the Medi-Cal provider manual.