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Workers' Compensation Board

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Frequently Asked Questions


General

  1. If I have a question on the CMS-1500 initiative, how can I get more information? Current news, FAQs, technical requirements and other resources can be found on the CMS-1500 Initiative section on the Board's website. If you have additional questions, please send an email to CMS1500@wcb.ny.gov. Questions posed to the dedicated mailbox will be promptly acknowledged. Responses will be posted to the FAQ section of the website regularly for the benefit of all stakeholders.
  2. Do all CMS-1500 submissions require a narrative or attachment? Yes, all CMS-1500 submissions (whether submitted through an XML submission partner or sent directly to the Board) require a medical narrative and/or attachment. Guidance on Medical Narrative and Attachment Requirements
    When the CMS-1500 initiative is implemented, XML submission partners will be instructed to reject CMS-1500 submissions that are not accompanied by the required medical narrative and/or attachment.
  3. Does the CMS-1500 data need to be in the same format for submission to the payer as it is to the Board? No, the Board has specific technical requirements for the electronic transfer of the CMS-1500. The payer's requirements for electronic transfer may be different. Payer requirements should be confirmed with them.
  4. Is the C-4.3 being replaced with the CMS-1500? No, it is anticipated that the C-4.3 will NOT be replaced by the required submission of the CMS-1500 form.
  5. Will a paper CMS-1500 be accepted by the Board? The Board will accept the paper form until the Chair mandates the XML submission of the CMS-1500 which is anticipated on or about January 1, 2020. While the XML submission may be mandated by the Chair, if a provider certifies that he or she is unable to submit electronically, there will be a way to continue to submit using paper.
  6. Will all payers accept paper CMS-1500s in 2019 and beyond? All payers will be required to accept paper CMS-1500s until it becomes mandatory to submit the CMS-1500 via XML on or about January 1, 2020.
  7. Where are the descriptions of the fields for the CMS-1500 located? The CMS-1500 Field Table Matrix (Excel) details the box-by-box descriptions
  8. Are there any anticipated changes for facilities that bill on the UB04? There are no anticipated changes at this time for facilities that bill using the UB-04.
  9. Will all payers still accept paper C-4, C-4.2 forms in 2019? All payers will be required to accept the paper C-4, C-4.2 forms until it becomes mandatory to submit the CMS-1500 via XML on or about January 1, 2020.
  10. Will EOBs still come on paper in 2019? EOBs will not have a requirement by the Board until on or about July 1, 2019, at which time, payers will be required to submit EOBs electronically to their XML submission partners (clearinghouses) upon adjudication of the associated electronic CMS-1500.
  11. Will the Board accept faxed C4s during 2019? The Board will accept faxed C-4s until it becomes mandatory to submit the CMS-1500 via XML on or about January 1, 2020.
  12. Will the Board accept faxed CMS-1500s in 2019 and beyond? The Board will not accept faxed copies of the CMS-1500 once it becomes mandatory to submit the CMS-1500 via XML on or about January 1, 2020.
  13. What address and fax should be used to send a CMS-1500 and narrative? Currently bills can be submitted to the Board by fax to (877) 533-0337 or by mail (NYS Workers' Compensation Board, Central Mailing Address, PO Box 5205, Binghamton, NY 13902-5205). Providers will be required to submit the CMS-1500 via XML on or about January 1, 2020.
  14. Will there be a list of insurer FEINs on the Board website? There will not be a list of FEINs on the Board's website.
  15. If there is no insurer or the insurer is undetermined, how will we submit only to the Board? The process for submission of the CMS-1500 for cases without an insurer (or the insurer is not determined) has not been established. Please continue to monitor the website for updates regarding this topic.
  16. If EOBs will be coming electronically, how will payments be made? Will checks be sent with no EOB or will a copy of an EOB be sent with payments? The Board is not mandating a change to the payers' payment method.
  17. Who pays the clearinghouse for their services? The party utilizing the clearinghouse services would pay them based on the agreement they have with each other.
  18. If form C-8.1 part B is going to be eliminated, will C-8.1 part A be a viable form for Part A filing? It is anticipated that the C-8.1A will remain in effect. More information on the EOB and C-8.1A/HP-1 process will be available at a future date.
  19. Will the changes of each phase take effect based on the bill's date of service or the date which the bill is submitted? The changes will be effective for any bill submitted on or after the effective dates. Mandatory electronic submission of CMS-1500 will be on or around January 1, 2020.
  20. Will the required timeframes for submitting the medical reports change as a result of this initiative? The timeframes for submitting medical reports to the Board and the Payer (set forth in NYCRR 325-1.3) are not changing as a result of this initiative. The following timeframes are still required:
    • Initial CMS-1500 (formerly the C-4, OT/PT-4 or the PS-4): within 48 hours of first treatment;
    • Subsequent CMS-1500 (formerly the C-4.2, OT/PT-4 or the PS-4): 15 days after first treatment, and thereafter for continuing treatment: after each follow-up visit scheduled when medically necessary but not more than 90 days apart.

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Providers

  1. Do I need to complete a new XML Submission Agreement to submit the CMS-1500 electronically even though I already completed one to submit the EC-4NARR? No, all providers who have already completed an XML Submission Agreement to submit XML data to the Board do not need to complete a new agreement to begin submitting the CMS-1500 electronically.
  2. I'm a provider who would like to start submitting CMS-1500 forms and required medical narrative and/or attachments. Do I need to register with the Workers' Compensation Board first? All health care providers who submit CMS-1500 forms using an XML submission partner must complete the registration for XML forms submission on the Board's website before the Board will accept their electronic submission of CMS-1500 documents through the XML forms submission process. You may use any Board authorized XML submission partners who have been approved to submit CMS-1500 bills and required medical narrative and/or attachments.
  3. The clearinghouse that I use is not registered as a Workers' Compensation Board XML Submission Partner. How can I submit the CMS-1500 using the XML submission process? Clearinghouses are encouraged to become XML submission partners. If your clearinghouse wishes to become a Board registered XML submission partner, please ask them to contact the WCB Customer Support Unit at: WCBCustomerSupport@wcb.ny.gov or call 844-337-6305 Monday through Friday during the hours 8:30 a.m. to 4:30 p.m. However, if your clearinghouse does not wish to become a submission partner directly, they may work with one of the authorized XML submission partners. All submission partners must test the CMS-1500 XML submission and be approved prior to implementation.
  4. Will pharmacies and durable medical equipment (DME) providers be required to submit the CMS-1500? Pharmacies and DME providers may continue, but will not be required, to submit the CMS-1500 under this initiative.
  5. Where can I obtain insurer information for billing purposes? Providers may obtain insurer information from the claimant or by using the Employer Coverage Search tool on the Board's website.
  6. Will there be any CMS-1500 requirements for chiropractors? There are no CMS-1500 requirements specifically for chiropractors. However, chiropractors should utilize the initial and subsequent narrative report requirements as shown on the Requirements page.
  7. What if we do not have the ability to send a CMS-1500 electronically? The Board will establish a hardship exception process for providers who are unable to meet the mandatory electronic reporting requirements. The actual process to do so will be posted to the website in the future.

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XML Submission Partners

  1. I'm a medical billing clearinghouse and would like to register with the Worker's Compensation Board to become an XML submission partner. Who do I contact to register? To start the registration to become a Board registered XML submission partner, please contact the WCB Customer Support Unit at: WCBCustomerSupport@wcb.ny.gov or call (844) 337-6305 Monday through Friday during the hours 8:30 a.m. to 4:30 p.m.
  2. Our organization is a current Workers' Compensation Board XML Submission Partner approved to submit the EC-4NARR. Will we need to execute a new agreement to submit the CMS-1500 in XML format? Yes, a new agreement will need to be executed.
  3. Will there be a testing phase prior to implementing the submission of CMS-1500 in XML format? Yes, you will be required to complete a testing phase to verify that you can submit a valid CMS-1500 to the Board.
  4. Is there an XML schema available? A draft CMS-1500 XML schema is available on XML Form Submission Schemas, Documentation and Samples page of the Board's website.
  5. Will the 837P or 837I format with attachment be accepted in place of the XML format? The 837P or 837I will NOT be accepted in place of the XML format.
  6. Where can I find the specifications for attaching provider narrative items (initial and follow-up reports) in XML electronic submission? There will not be a schema created to collect medical narratives/attachments. The attachments need to be a TIF or text file modeled after the narrative attachment requirements found on the requirements page. Sample submissions can be found on the XML Form Submission Schemas, Documentation and Samples.

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Payers

  1. What information will a payer be required to submit to the XML submission partner upon receipt of a CMS-1500 bill? The payer must submit the following information to the XML submission partner:
    • Unique Document ID Number
    • Unique Narrative Document ID Number
    • Carrier Acknowledgment Date [YYYY-MM-DD]
    • Carrier W Number
    • XML Partner Name or ID Number
    • WCB Case Number (if assembled)
  2. If a payer has no claim on record for a specific injury date, is it required to accept a CMS-1500 from an XML submission partner? Yes, a payer may not reject a CMS-1500 from the XML submission partner if a claim (FROI) has not yet been received.
  3. Will all payers be required to accept the CMS-1500s electronically? All Payers will be required to accept the CMS-1500 electronically on or about January 1, 2020. Web submission via the Board's website will not be available.
  4. Will the carrier be required to issue C-8.1 for any bill missing a narrative or will the EOB stating the omission be sufficient? The electronic submission of the EOB will not begin until Phase 2 of this initiative on or around July 1, 2019. This process is still under development, however the Board plans to use EOB denial codes to replace those objection reasons currently on the C-8.1B and C-8.4. Please continue to monitor the Board's website for updates on this information.
  5. How will carriers know what clearinghouse the provider is using? The electronic submission requirements for the CMS-1500 include a field for the XML submission partner identifier (in field 8).
  6. At what point does the 45-day rule start for payment? The payer must remit payment within 45 days from when the bill is received by the payer's clearinghouse or the payer themselves (whichever is earlier).

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