NYWCB Initiative: Electronic Submission of CMS-1500, and Explanation of Benefits

Objectives:

• Increase health care provider participation in the workers’ compensation system and improve injured workers’ access to timely, quality medical care
• Reduce the administrative burden and increase provider participation by removing most other billing forms and converting to the CMS-1500 form, the universal claim form used by medical providers to bill the Centers for Medicare and Medicaid Services (CMS) as well as health insurers
• CMS 1500 Initiative Overview: http://www.wcb.ny.gov/CMS-1500/index.jsp

Consequences of non-compliance:

• Provider bills may be found legally defective
• The NYSWCB expects all Payers, Carriers, TPAs and Healthcare Providers/Suppliers to implement the CMS-1500 requirements

Provider:

• Provider submission of professional NY WC CMS-1500 bills and attachments electronically to payers and via XML to the NYSWCB
• Providers are reminded to register for XML submission now- do not delay

All Healthcare Providers* rendering professional WC services in NY (including those now listed under the Expanded Provider Law) must:

• Become Board-Authorized, obtaining a NYSWCB-issued Authorization Number and Rating Code to submit with all professional WC CMS-1500 bills
• Register for the Medical Portal http://www.wcb.ny.gov/medicalportal/ 
• Register for XML authorization and execute the WCB-issued legal agreement: http://www.wcb.ny.gov/content/ebiz/XMLSubmissions/xmlSubmissions_howtoreg.jsp
• Submit CMS-1500 bills and required attachments electronically to payers, and via XML to the NYSWCB: http://www.wcb.ny.gov/CMS-1500/requirements.jsp

*Some providers such as those out of state, emergency/urgent care or DME suppliers are not required to become authorized, however should register for the NYSWCB Medical Portal and for XML submission.

Healthcare providers that must become Board authorized include those listed below. Other provider types are not eligible for authorization:

• Physicians
• Chiropractors
• Psychologists
• Podiatrists
• Physical Therapists
• Occupational Therapists
• Acupuncturists
• Clinical Social Workers
• Nurse Practitioners
• Physician Assistants

Payer:

• Payer acceptance of CMS-1500 bills and attachments electronically
• Payer transmission of electronic acknowledgment of bill receipt
• Payer transmission of EOBs electronically to providers

Effective October 1, 2021, Payers must accept electronic submissions of the CMS-1500 with attachments and provide electronic acknowledgments

Effective July 1, 2022, Payers must:

• Identify all reasons for objection at the initial determination of the medical bill
• Use the new Notice of Treatment Issue/Disputed Bill (Form C-8.1) and Notice to Health Care Provider and Injured Worker of a Carrier’s Refusal to Pay All (or a Portion of) a Medical Bill Due to Valuation Objection(s) (Form C-8.4) with applicable Claim Adjustment Reason Codes (CARCs) to object to medical bills
• Begin incorporating standard CARC code sets: http://www.wcb.ny.gov/CMS-1500/WCB-CARC-RARC-codes.pdf
• Provide the Explanation of Benefits electronically to health care providers, (identifying the same CARCs as specified the C-8.1 or C-8.4)

Stay informed on NYWCB news:  wcb.ny.gov/notify