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Provider Notice Issued 11/24/2021

Date:   November 24, 2021        

To:       All Medical Assistance Program Providers

Re:      Final Phase-Out of Fee-for-Service Paper Claims and Attachments


 This notice informs providers that effective with claims received on and after December 15, 2021, the Department will no longer accept paper claims. This update impacts fee-for-service paper claims for all institutional and non-institutional Medical Assistance Program providers.

The Department notified providers of the initial phase toward paperless billing via a provider notice dated October 17, 2019. As the final step, the Department has developed a process that allows providers to utilize the Medical Electronic Data Interchange (MEDI) System for electronic claim submission and uploading PDF attachments. If providers submit claims in a format other than MEDI, providers may use the Attachment Upload Portal, accessible at

Please see Attachment A for instructions on using the Attachment Upload Portal.

Providers should use one Attachment Control Number (ACN) for the entire claim and utilize the first ACN field available within the X12 claims transactions to facilitate the association of their submitted electronic attachments.

Attachments Required for HFS Processing

FormReport Type Code in Segment PWK01
HFS 1624 – Override Request Form (for non-institutional providers)OZ
HFS 1624A – UB-04 Override Request Form (for institutional providers)OZ
HFS 1977 – Acknowledgement of Receipt of HysterectomyCK
HFS 2189 – Sterilization Consent FormCK
HFS 2432 – Split Billing Transmittal (for Medical Spenddown program)10
HFS 2803 – Optical Prescription Order
Form 1409 - Optical Prior Approval – only use when submitting with OPO and requesting polycarbonate lenses for adults
Prior Approval of Gender Affirmation03
Transplant claims – Initial Authorization letter and Discharge summary15
Transplant Annual Discharge Summary21
Medicare EOBEB
Transplant Authorization Letter (other than initial)HC
Forensic Claims (for Bureau of Behavioral Health)OD


Please see Attachment B for additional report type coding for any other required attachments for adjudication of the claim submission (previously required on paper) as referenced in the specific Chapter 200 provider handbook.

Attachment Instructions

Attachments required for claim processing must be uploaded into MEDI or the Attachment Upload Portal. Providers are strongly advised to upload the attachment before submitting the claim. The attachment must be present and successfully found within the Department's Attachments Warehouse at the time of claim editing. If the attachment is not found, the claim will be immediately rejected.

Beginning December 15, 2021, the Department will return any paper claim forms and corresponding documentation received.

  • Medical Electronic Data Interchange (MEDI)


The MEDI Authorization System is available free of charge. The MEDI Getting Started page presents what is required to use the applications. No additional hardware or special software is needed. The MEDI system is available to enrolled providers and their authorized staff, claim submitting agents and payees.  

Providers may also submit electronic claims through the following mediums:

  • X12 837 Professional Standard, Version 5010A
  • X12 837 Institutional Standard, Version 5010A

The Department accepts non-institutional claims in the X12 837 Professional standard, Version 5010A and institutional claims in the X12 837 Institutional standard, Version 5010A.

Pharmacies must bill electronically through the Pharmacy Benefits Management System.

  • Recipient Eligibility Verification (REV)

The Recipient Eligibility Verification (REV) system is an interactive electronic system which allows providers to: verify a participant's eligibility; submit claims electronically; check the status of claims in processing, and download batches of claim information. Providers access the REV system through vendors (independent contractors) who have agreements with the Department to provide this service.

The 837P and 837I Companion Guides have been updated with electronic attachment information. Questions regarding this notice may be directed to a billing consultant in the Bureau of Professional and Ancillary Services at 877-782-5565.


Kelly Cunningham, Administrator
Division of Medical Programs


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