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 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, the universal claim form used by medical providers to bill the Centers for Medicare and Medicaid Services (CMS) as well as health insurers.
The initiative will leverage providers' current medical billing software and medical records while promoting a more efficient workers' compensation system.
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)
The CMS-1500 must be submitted with a detailed narrative report to be considered a valid submission The Board has developed a template that providers can use to create the medical narrative report that accompanies provider submissions of the CMS-1500. A sample of the template can be found on the CMS-1500 Requirements page.
CMS-1500 Submission Process
- Providers are strongly encouraged to partner with an XML submission partner who will ensure that the medical bill and narrative attachment are sent and accepted by the correct payer. However, "paper" CMS-1500 submissions will be permitted when the CMS-1500 requirement goes into effect in July 2022.
- If partnered with a clearinghouse (XML submission partner), providers do not need to complete a CMS-1500 form but rather submit their bill and narrative attachment to the XML submission partner they have a relationship with in the agreed-upon format.
- The XML submission partner will forward the bill and narrative attachment to the workers' compensation payer.
- The payer will accept the CMS-1500 from the XML submission partner and return electronic acknowledgement of receipt.
- The XML submission partner will forward the acknowledgement, including receipt date, to the provider.
- XML submission partners will transmit, in the designated XML format, the CMS-1500 forms, narrative attachments, and payers' acknowledgements of receipt to the Board.
When CMS-1500 forms are submitted to the Board using the XML submission process, providers SHOULD NOT mail, fax or email a duplicate paper form to the Board.
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