In order to increase health care provider participation in the workers' compensation system and improve injured workers' access to timely, quality medical care, the Workers' Compensation Board (Board) made a strategic decision to transition toward making the CMS-1500 form a required form.
Providers have indicated that the unique paperwork requirements currently in the workers' compensation system are time consuming to complete. To reduce the administrative burden and increase provider participation, the Board will consolidate and eliminate certain medical billing forms and convert 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. Careful review and discussion with various stakeholders confirms that the CMS-1500 is easy to use and provides all the necessary information.
The Board will replace the following forms with the CMS-1500:
- Doctor's Initial Report (Forms C-4, EC-4)
- Continuation to Carrier/Employer Billing Section (Form C-4.1)
- Doctor's Progress Report (Forms C-4.2, EC-4.2)
- Ancillary Medical Report (Forms C-4AMR, EC-4AMR)
- Doctor's Narrative Report (Form EC-4NARR)
- Occupational/ Physical Therapist's Report (Forms OT/PT-4, EOT/PT-4)
- Psychologist's Report (Form PS-4)
- Ophthalmologist's Report (Form C-5)
Providers do not need to complete a Form CMS-1500 but rather submit their bill to the clearinghouse (XML submission partner) they have a relationship with in the agreed upon format. The clearinghouse will then forward the bill to workers' compensation payers or self-insured employers. The payers will accept Form CMS-1500 from the clearinghouse and return electronic acknowledgements of receipt of Form CMS-1500 to the clearinghouse. The clearinghouse will then forward the acknowledgements (including receipt date) to the providers. The Board will receive Form CMS-1500s, narrative attachments and payers' acknowledgements of receipt from XML submission partners in a designated XML format. The initiative will leverage providers' current medical billing software and medical records while promoting a more efficient workers' compensation system.
In response to numerous payers’ and health care providers’ questions after the Workers’ Compensation Board’s CMS-1500 training video and webinars held in September 2019, the Board has developed a medical narrative report template that can be used to create the medical narrative report that accompanies provider submissions of the Form CMS-1500. A copy of the template, as well as line-by-line instructions, can be found in the CMS-1500 Requirements page.
Questions can be directed to: CMS1500@wcb.ny.gov
View a video presentation for providers on CMS-1500 and the Expanded Provider Law.
Several XML Submission Partners have been approved for CMS-1500 submissions: View XML Submission Partner Status
June 14, 2021
- Additional Payer FAQs
- Updated Timeline. Payers will be mandated to accept electronic medical bills from clearinghouses and transmit Explanation of Benefits / Explanation of Review electronically on October 1, 2021. Beginning, July 1, 2022, it will become mandatory for Providers to submit the Form CMS-1500 and for Payers to use specific Claims Adjustment Reason Codes (CARC).
April 12, 2021
- Additional Provider, Payer and XML Submission Partner FAQs.
- Treating Health Care Provider's Agreement for XML Submission of CMS-1500 Forms and Medical Narrative Reports no longer needs to be notarized.
- The CMS-1500 Guide for New XML Submission Partners has been revised to reflect updated provider agreements (which no longer require notarization).