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Workers’ Compensation Board

WCB Information Related To Novel Coronavirus (COVID-19)

Frequently Asked Questions


General

  1. Will there be a regulation change when the electronic submission of the CMS-1500 becomes mandatory? Yes, there will be a change in regulation prior to the mandatory electronic submission of the CMS-1500. Stakeholders will be provided an opportunity to comment on proposed regulations. The Board anticipates there will be a 60-day comment period associated with this regulation change.
  2. 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.
  3. Do all CMS-1500 submissions require a narrative or attachment? Yes, all Form CMS-1500 submissions (whether submitted through an XML submission partner or sent directly to the Board) require a medical narrative and/or attachment. The Board has also developed a medical narrative report template which may be completed for each provider’s submission of the Form CMS-1500. A copy of the template and the associated narrative requirements can be found on the CMS-1500 section of the Board’s website at http://www.wcb.ny.gov/CMS-1500/requirements.jsp. XML submission partners have been instructed to reject Form CMS-1500 submissions that are not accompanied by the required medical narrative and/or attachment.
  4. 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.
  5. 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.
  6. 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.
  7. Where are the descriptions of the fields for the CMS-1500 located? The CMS-1500 Field 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? 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.
  10. Will EOBs still come on paper during Phase 1 of the CMS-1500 initiative? EOBs will not have a requirement by the Board until Phase 2 is implemented, 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 using specific CARC codes to identify the reason for the objection.
  11. What methods can be used to submit the CMS-1500 during Phase 1? The Form CMS-1500 and its related medical narrative report can be submitted to the Board by the methods shown on the following webpage: http://www.wcb.ny.gov/content/main/Forms.jsp. It is preferred that providers use the electronic means shown (email or web-upload) prior to the mandatory implementation of XML electronic submission.
  12. What address should be used to send a CMS-1500 and narrative? The Form CMS-1500 and medical narrative attachment can be sent to the Board by mail, email or web upload. Details on sending information to the Board can be found http://www.wcb.ny.gov/content/main/Forms.jsp.
  13. Will there be a list of payer FEINs on the Board website? There will not be a list of FEINs on the Board's website.
  14. If there is no payer or the payer is undetermined, how will we submit only to the Board? The provider's office should obtain the employer's name and address from the injured worker. If they are unaware of the correct entity who they work for, they should contact their human resource office or supervisor. As you may know, in New York State, employers are required to post the C-105 (Notice of Compliance – Workers' Compensation Law) in a conspicuous place in the workplace identifying the employer's workers' compensation insurance carrier name, address, phone number and policy number. The provider can use the Employer Coverage Search app to search for the employer's insurer.
  15. 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.
  16. Who pays the XML submission partner for their services? The party utilizing the XML submission partner services would pay them based on the agreement they have with each other.
  17. 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 be split from the C-8.1B, but will remain in effect. More information on the EOB and C-8.1 process will be available in the coming weeks.
  18. 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.
  19. 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.
  20. When electronic submission of the EOB is implemented in Phase 2, how will the denial codes replace the objection currently on the C-8.1B and C-8.4? The Board plans to map the current objection codes to the Claims Adjustment Reason Codes (CARC) used for the X12 835 standard. The required CARC codes will be published in the coming weeks.

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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.   Listing of Providers Authorized to Submit XML Data (MS Excel)   Information on how to Send National Provider Identifier (NPI) to the Board.
  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 approved 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. Clearinghouses interested in becoming an XML Submission Partner will need to register first with the Board. All submission partners must test the CMS-1500 XML submission and be approved prior to implementation. However, if your clearinghouse does not wish to become a submission partner directly, they may work with one of the approved XML submission partners.
  4. 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.
  5. Will there be any CMS-1500 requirements for chiropractors? There are no unique CMS-1500 requirements specifically for chiropractors. Chiropractors should utilize the initial and subsequent narrative report requirements as shown on the Requirements page.
  6. What if we do not have the ability to send a CMS-1500 electronically? The Board may establish a hardship exception process for providers who are unable to meet the mandatory reporting requirements through an XML submission partner.
  7. How do I become a Board Authorized Provider? Instruction for how to Apply to Become an Authorized Provider
  8. How do I know if I have previously signed up to submit medical bills electronically?   Listing of Providers Authorized to Submit XML Data (MS Excel)   Information on how to Send National Provider Identifier (NPI) to the Board
  9. How do I know which clearinghouses are planning to become a CMS-1500 XML Submission Partners? The Board has published a listing of clearinghouses who are interested, testing or approved to become an XML Submission Partner for the CMS-1500.
  10. Will the Expanded Provider Law have any effect on how I submit the CMS-1500 via XML? If authorized, the new provider types (licensed clinical social workers, nurse practitioners, acupuncturists, physician assistants, occupational therapists and physical therapists) can begin treating injured workers on January 1, 2020. Read more about the Expanded Provider Law on the New Provider Legislation page. Once authorized, new provider types must bill as the rendering provider. The new providers will also be required to complete the registration for XML forms submission on the Board’s website before the Board will accept their electronic submission of Form CMS-1500 through the XML forms submission process.
  11. What are the requirements for the TIFF-formatted medical narrative and image of the completed CMS-1500? All of the images must be legible and of good quality. Specific requirements that the upload process will check for and fail if not met include:
    • TIFF4 Format (aka TIFF using ‘CCITT Group 4 Fax’ compression)
    • Fill Order must be ‘Most Significant Bit (MSB) to Least Significant Bit (LSB)’
    • ‘Single strip’ images only
    • No tiled images allowed
    • 200 dpi
    • Black and White only (color depth: 1 bit)
    • One image per file (no multi-page TIFF files allowed, A duplex document should be converted to two image files)
  12. How should CMS-1500 bills be submitted for surgery when the surgeon has been assisted by another physician, nurse practitioner or physician assistant? The surgeon's Rating Code should be entered in field 19. The surgeon's License Number and NPI should be entered in field 24J and the bill should be signed by the surgeon in field 31. Modifier 83 is to be used in field 24D to identify assistant services provided by a physician assistant or nurse practitioner. Modifier 80 would be used to identify surgery assistant services provided by a physician. The name, License Number and NPI of anyone providing surgery assistant services should be included as part of the attached medical narrative. Examples of how different types of providers should fill out the CMS-1500 can be found on the Board's website.

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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? Clearinghouses interested in becoming an XML Submission Partner will need to complete an online registration with the Board.
  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 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? The Form CMS-1500 medical narrative template can be found on the CMS-1500 section of the Board’s website at http://www.wcb.ny.gov/CMS-1500/requirements.jsp. The narrative attachments need to be a TIFF or text file modeled after the narrative template requirements found on the same page. If the template is utilized by the provider, it should precede other medical narrative documents.
  7. Besides the XML rendering for the CMS-1500, what must be contained in the XML file transmitted to the Workers' Compensation Board? Each CMS-1500 submitted via XML must include a TIFF-formatted medical narrative and a TIFF-formatted image of the completed CMS-1500.
  8. Do all clearinghouses need to become XML submission partners? No, only those clearinghouses that are sending XML files to the Workers' Compensation Board need to become XML submission partners.
  9. What will be included in the test plan? There will be two components to the test plan: 1) Preliminary; and 2) Parallel. Preliminary testing is required to allow the XML partner to demonstrate to the Board that they can construct a submission that is properly formatted. It is not necessary to use production data for preliminary testing. Parallel testing will occur after successful preliminary testing. This is to ensure that data received electronically from the medical provider is properly mapped to the submitted XML file and CMS-1500 image, and that the same information (mapped fields) submitted by the provider on the current production form is contained in the parallel test submission. Before the parallel test phase begins, the submitter needs to identify medical providers and payers to participate in the testing phase with them. Additional details of the test plan is available in the CMS-1500: A Guide for New XML Submission Partners adobe pdf.
  10. Where do the XML submission partners obtain the WCB authorization number and rating code? Provider WCB authorization numbers and rating codes can be found Listing of Providers Authorized to Submit XML Data (MS Excel)
  11. How will I know the payer acknowledgment date if the CMS-1500 has not been sent electronically to the payer? The payer acknowledgment date will not be required for paper submissions, during Phase 1.
  12. What is the timing of submission of the CMS-1500 to the WCB? The CMS-1500 forms and medical narrative reports should be submitted to the Board immediately upon acknowledgment by the payer and no later than seven business days after receipt from the treating provider.
  13. If any non-required field is unknown to the XML submission partner, e.g. claimant's social security number, how should this be transmitted to the Board? Are there default values that should be used in these cases such as "Unknown" or "999999999"? If the XML submission partner does not have the data for a non-required field, the field should be left blank.
  14. What are the requirements for the TIFF-formatted medical narrative and image of the completed CMS-1500? All of the images must be legible and of good quality. Specific requirements that the upload process will check for and fail if not met include:
    • TIFF4 Format (aka TIFF using ‘CCITT Group 4 Fax’ compression)
    • Fill Order must be ‘Most Significant Bit (MSB) to Least Significant Bit (LSB)’
    • ‘Single strip’ images only
    • No tiled images allowed
    • 200 dpi
    • Black and White only (color depth: 1 bit)
    • One image per file (no multi-page TIFF files allowed, A duplex document should be converted to two image files)
  15. Since NPI numbers will be used to validate electronic submission of the CMS-1500 bill, how can I ensure that the providers we are supporting have submitted their NPI to the Board? Please refer to Listing of Providers Authorized to Submit XML Data (MS Excel) for information on providers who have been approved for electronic/XML submission. If the Board has not yet received an NPI number for a particular provider, it will be notated in column D. Information on how to Send National Provider Identifier (NPI) to the Board.

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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:
    • Insurer Acknowledgment Date [YYYY-MM-DD]
    • Insurer W 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 are required to accept a CMS-1500 in paper form at the present time and will be required to accept it electronically when it becomes mandatory in Phase 2. Payers should currently be in the process of implementing electronic acceptance of the CMS-1500.
  4. Will the payer be required to issue C-8.1 for any bill missing a narrative or will the EOB stating the omission be sufficient? The Board has not changed the process to object to a legally defective bill. Note: All CMS-1500 submissions require a medical narrative and/or attachment. XML submission partners will reject CMS-1500 submissions not containing a medical narrative.
  5. Should a payer submit an objection (and CARC code) to the Board when reducing a provider’s medical bill to align with the Relative Value Unit (RVU) limitations in the Medical Fee Schedule? No, the payer may reduce the amount of the bill to 12, 15 or 18 RVUs for evaluation services and modalities, as set forth in the applicable Medical Fee Schedule. The payer should not submit an objection to the Board. This RVU reduction typically applies to chiropractic services, physical therapy modalities, occupational therapy modalities and acupuncture services.
  6. How will payers know what XML submission partner the provider is using? Payers will be responsible for returning an acknowledgement of receipt back to the clearinghouse from which they received the CMS-1500 billing data/medical narrative attachments.
  7. At what point does the 45-day rule start for payment? The payer must remit payment (or object to payment of the bill) within 45 days from when the bill is received by the payer's clearinghouse or the payer themselves (whichever is earlier).
  8. We are a third-party administrator who handles claims for self-insured employers and insurance carriers, will our information be captured anywhere on the CMS-1500? Yes, third-party administrator information will be captured in CMS item 0 (payer name, address, city state and zip). If known, the carrier W number should be entered in item 0 (carrier W#).
  9. How do I know which clearinghouses are planning to become a CMS-1500 XML submission partners? The Board has published a listing of clearinghouses who are interested, testing or approved to become an XML Submission Partner for the CMS-1500.

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Webinar Q&As - September 2019

  1. Can I use and submit a CMS-1500 now? Providers may voluntarily transmit CMS-1500 medical bills (and required medical narratives, and/or attachments as applicable) through their clearinghouses (XML Submission Partners) to workers' compensation payers, including insurers, third party administrators or self-insured employers. Mandatory submission will be during Phase 2 of the initiative.
  2. What kind of image of the CMS-1500 should I provide? In addition to provide a quality image, we want to stress the importance of submitting quality content. The Board has developed a medical narrative report template that can be used to supplement 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 on the CMS-1500 section of the Board’s website at http://www.wcb.ny.gov/CMS-1500/requirements.jsp.
  3. 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. When the XML submission is mandated by the Chair, the Board may establish a hardship exception process for providers who are unable to meet mandatory electronic reporting requirements. All payers will also be required to accept the paper C-4, C-4.2 forms until it becomes mandatory to submit the CMS-1500 via XML.
  4. How will I know when my bill has been accepted by the payer? By submitting electronically, there is verifiable acknowledgement data on record to show when the bill was received by the payer. The payer must remit payment within 45 days from the acknowledgement date.
  5. How do I know if I have previously signed up to submit medical bills electronically? The Board has posted on its website a listing of all providers who have previously signed up for XML forms submission.
  6. Will EOBs come on paper during Phase 1 of the initiative? EOBs will not have a requirement by the Board until Phase 2 is implemented, 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, using specific CARC codes if objecting to payment of a bill.
  7. If there is no payer or the payer is undetermined, how will we submit only to the Board? The provider's office should obtain the employer's name and address from the injured worker. If they are unaware of the correct entity who they work for, the employee should contact their human resource office or supervisor. As you may know, in New York State, employers are required to post the Notice of Compliance - Workers' Compensation Law (Form C-105) in a conspicuous place in the workplace identifying the employer's workers' compensation insurance carrier name, address, phone number and policy number. Providers may also use the Employer Coverage Search tool which can be found on the Board's website.
  8. 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.
  9. Will all payers accept a paper CMS-1500 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.
  10. Will there be a regulation change when the electronic submission of the CMS-1500 becomes mandatory? Yes, there will be a change in regulation prior to the mandatory electronic submission of the CMS-1500. Stakeholders will be provided an opportunity to comment on proposed regulations. The Board anticipates there will be a 60-day comment period associated with this regulation change.
  11. Do all CMS-1500 submissions require a narrative or attachment? Yes, all Form CMS-1500 submissions (whether submitted through an XML submission partner or sent directly to the Board) require a medical narrative report attachment. The Board has developed a medical narrative report template that can be used to supplement the attached medical narrative report that accompanies provider submissions of the Form CMS-1500. The medical narrative report template can be found on the CMS-1500 section of the Board’s website at http://www.wcb.ny.gov/CMS-1500/requirements.jsp. The template includes at the top of the page the three mandatory elements to include with most narratives: the patient’s work status, causal relationship of the injury to the patient’s work activities, and temporary impairment percentage. Providers must also provide within their narrative, examination findings including the history of the injury/illness, objective findings based on the clinical evaluation, the patient’s plan of care and the diagnosis(es)/assessment of the patient.
  12. 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. To view the requirements, visit the XML Forms Submission Overview page. The payer's requirements for electronic transfer may be different. Payer requirements should be confirmed with them.
  13. Why does the provider agreement state that reports submitted to an XML Submission Partner by me must be submitted to the Board within 7 days of receipt? The intent of the 7-day period is to allow the providers, XML Submission Partners and payers to work collaboratively during this time to make corrections to the electronic transmission allowing it to flow through the system without error.
  14. Is the Doctor's Report of MMI/Permanent Impairment (Form C-4.3) being replaced with the CMS-1500? No, it is anticipated that the Doctor's Report of MMI/Permanent Impairment (Form C-4.3) will NOT be replaced by the required submission of the CMS-1500 form.
  15. 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 email CMS1500@wcb.ny.gov. You may also subscribe to receive email or text notifications from the Board.
  16. When can I start using CMS-1500? The Board has accepted the submission of the CMS-1500 since October 1, 2015, as described in the following subject number regarding the change (http://www.wcb.ny.gov/content/main/SubjectNos/sn046_785.jsp). The CMS-1500 can currently be electronically submitted to the Board by email or web-upload, as well as through their approved XML submission partner. XML submission partners are currently testing with the Board to submit the CMS-1500 via XML. When approved, the XML submission partner status will be updated on the Board’s website. Once a provider’s XML submission partner is approved, their providers’ bills maybe submitted to the Board using XML submission. Please see List of XML Submission Partners for XML Submission Partners who have been approved by the Board.
  17. During Phase 1 will the Board accept photocopies of the HCFA1500 form, or does it require the original? During Phase 1 of the initiative, providers may submit either the CMS-1500 or C-4 forms to the Board by email, web-upload, or through an approved XML submission partner. It does not have to be the original. It will be mandatory to partner with a clearinghouse for the XML submission of the CMS-1500 (which will not require use of a paper CMS-1500 form) during Phase 2.
  18. Currently, we fax Form C-4.2, and other forms with medical records to the Board then mail it to the actual insurance carrier. Is this being replaced by the XML process? Yes, the XML process will replace other methods of sending medical reports including: mail, email fax and web upload.
  19. To clarify the answer to a previous question, after a medical bill is received by the payer from the clearinghouse, is the payer required to forward the medical bill to the Board? No, the payer should not forward the medical bill to the Board. The payer will acknowledge (to the clearinghouse) they received the bill and the clearinghouse will send the bill to the Board along with the payer’s acknowledgment date.
  20. What is the email address to submit the claims? Medical bills/reports may be submitted to the Board by email at wcbclaimsfiling@wcb.ny.gov. However, the Board encourages providers to partner with a clearinghouse for the XML submission of the CMS-1500 now, during the voluntary phase of the initiative.
  21. Can I fax CMS-1500 to the Board as I did with the C-4 NARR? No.
  22. Can a provider submit CMS-1500 to carriers and the Board and not use a clearinghouse? During Phase 2 of the initiative, providers will be required to submit their bills through a clearinghouse. They will not be able to submit the CMS-1500 directly to carriers or the Board. WCB encourages providers to start working with an approved clearinghouse now during the voluntary phase of the initiative.
  23. Will physicians be able to see claimant medical records through clearinghouses? Clearinghouses provide their own array of services to medical providers with whom they contract. Please confirm services offered directly with the clearinghouse.
  24. Will clearinghouses be using medical records from Medicare, Medicaid or private insurers to dispute WCB claims? Data sharing outside of the workers’ compensation system is not part of the CMS-1500 initiative. However, please note that providers should not be billing workers’ compensation payers and other insurers simultaneously for the same services. According to Workers’ Compensation Law 13(a), employers shall promptly provide for an injured employee such medical, dental, surgical, optometric or other attendance or treatment.
  25. For the first initial doctor's visit, should we use Form C-4 or CMS-1500 form? For all doctor’s visits, including the initial one, providers should use the CMS-1500 with an accompanying narrative report.
  26. I’m sorry one more question. Are we still using Form C-4.2 for follow up patients or just the CMS- 1500? For all doctor’s visits (except permanency evaluations reported on a C-4.3), providers should use the CMS-1500 with an accompanying narrative report.
  27. Where can we find the CMS-1500 form? Examples of the CMS-1500 can be found on the Board’s website.
  28. Is the CMS-1500 form the same one as the OMB-0935-1197 form 1500? The format of the form is the same, but the information collected in individual fields may be different for workers’ compensation. Please see the Field Matrix on the Board’s website to determine the information required for each field of the form.
  29. Where can we put the provider's WCB authorization# and rating code? The provider’s authorization number and rating code are entered in field 19 on the CMS-1500. Please see the Field Matrix on the Board’s website to determine the information required for each field of the form.
  30. Where will the payer’s acknowledgement be located and will this be our new evidence of the claim being submitted as timely filing? The acknowledgement date will be entered in field 19 of the CMS-1500 by the clearinghouse. The Board will use the acknowledgement date to confirm timely filing.
  31. Where on the CMS-1500 is the NP/PA info going, their name or numbers, etc. The new expanded provider legislation enables NP’s and PA’s to become authorized by the Board and bill for their services. Read more about the Expanded Provider Law on the New Provider Legislation page. Once authorized, the NP/PA name/electronic signature may be entered in field 31 and their WCB authorization/rating code may be entered in field 19.
  32. Previously, PT/OT 4 forms are sent to the payer, the Board, the referring physician, the patient or patient's attorney. Is this still required and if so how will that be done? Workers’ compensation law only requires that medical reports be filed with the Board and the carrier/payer. It is not legally required to file bills/reports with the claimant, but providing a hard copy to the claimant after an examination is good practice. The claimant also has access to all medical report filed by their physicians in eCase.
  33. With regard to the C-4.3 MMI/Permanency Forms, we are currently submitting 1500 forms with a copy of the C-4.3. Is it necessary to submit both forms or should we just be submitting Form C-4.3 since both the charge and medical information is included on the same form? Providers should only submit the C-4.3 form following a permanency exam.
  34. Aside from the CMS-1500, is there a format on how the narrative should be submitted? Is there a certain form the narrative should be on? Yes, the Board has developed a medical narrative report template that can be used to supplement the medical narrative report that accompanies provider submissions of the Form CMS-1500.

    The medical narrative report template can be found on the CMS-1500 section of the Board’s website at http://www.wcb.ny.gov/CMS-1500/requirements.jsp.
  35. Will there be a template developed for the information required in the new narrative? Many of us have electronic records and our technical support can setup those templates. Yes, the Board has developed a medical narrative report template that can be used to supplement the medical narrative report. See http://www.wcb.ny.gov/CMS-1500/requirements.jsp for template details/requirements.

    In lieu of completing the template, the provider’s own medical narrative report will be acceptable, if the three mandatory elements (patient’s work status, causal relationship and temporary impairment percentage) are included.
  36. What are the three unique workers compensation requirements for the narrative? The three mandatory elements to be included with most narratives are : 1) the patients work status; 2) causal relationship of the injury to the patient’s work activities; and 3) temporary impairment percentage. See http://www.wcb.ny.gov/CMS-1500/requirements.jsp for additional information on the medical narrative template details/requirements.
  37. Do people with a life-time approved benefit need to have attachments? Medical narratives and/or attachments are required for all medical bills, regardless of whether the claimant has a permanent classification.
  38. How will you be able to attach the medical narrative to the CMS-1500 that is submitted electronically? Approved clearinghouses (XML submission partners) can attach medical narratives to XML data using a .TIFF file. Check with your clearinghouse for their preferred method of obtaining narratives/attachments.
  39. Will there be an area on the Board’s website where narratives could be uploaded manually if need be? It is anticipated that the current functionality for urgent uploads of medical reports needed for a hearing will continue. Details on sending information to the Board can be found http://www.wcb.ny.gov/content/main/Forms.jsp.
  40. Is it obligatory to use a clearinghouse to submit the CMS-1500, or can it be done directly similarly to the current ec4 process? In Phase 2, providers will be required to submit the CMS-1500 through an approved clearinghouse. Providers may continue to submit the current C-4 forms during Phase 1 of the initiative although the Board highly recommends early adoption of the CMS-1500 through a clearinghouse.
  41. How will we know the clearinghouses that will be or are already approved? A list of clearinghouses is located on the Board’s website with their status and contact information.
  42. What if our clearinghouse is not on the approved list of XML partners? Clearinghouses may register to become XML submission partners on the Board’s website. They will be required to successfully complete testing with the Board to become approved for production XML submission of the CMS-1500. However, if your clearinghouse does not wish to become a submission partner directly, they may partner with one of the approved XML submission partners to facilitate sending your medical bills to the correct payer and the Board.
  43. When using a clearinghouse, will the payment also go through them? In Phase 2, it is expected that explanation of benefits would be returned from the payer to the provider through the clearinghouse, but not necessarily payment transactions.
  44. Would the medical provider need to use the same clearinghouse as the carrier? The medical provider will not need to use the same clearinghouse as the carrier. Clearinghouses have multiple agreements with other clearinghouses to pass bills electronically ensuring timely submission to carriers.
  45. Our office sends paper claims and does not use a clearinghouse. Will our office be required to use a clearinghouse? The Board expects most providers will need to partner with a clearinghouse. However, the Board may establish hardship exception criteria for providers who are unable to meet the mandatory electronic reporting requirements.
  46. I am confused regarding having to register to submit the XML forms. If we currently bill workers comp, should we still be registering? And what exactly does XML mean? XML is the electronic format by which clearinghouses will send CMS-1500 data to the Board. To be eligible for XML submission of CMS-1500 forms, providers must first register with the Board. Upon successful registration, the Board will mail a provider agreement for the provider to execute, notarize and return to the Board. The Board will notify the provider by e-mail, at the e-mail address provided on the registration, that he/she may inform their Board-approved XML submission partner that CMS-1500 XML submission may commence. Providers who currently submit XML data to the Board (i.e., on an EC-4NARR) do not need to execute a new legal agreement. A listing of providers who have already executed an XML agreement is on the Board’s website.
  47. And what is the deadline of XML registration? There will not be a deadline for XML registration until Phase 2 of the initiative is implemented.
  48. If the attached medical report is missing the required claim information, will it still be accepted by the Board? Can the carrier object to a bill if information is missing? If the narrative report is completely missing from the claim, it will not be accepted by the payer or the Board.

    The Board has developed a medical narrative report template that can be used to supplement 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 on the CMS-1500 section of the Board’s website at http://www.wcb.ny.gov/CMS-1500/requirements.jsp. This initiative will not change the reasons why a carrier/payer may object to payment of a bill.
  49. How will parties be notified that the CMS-1500 has been "rejected"? Clearinghouses will be responsible to ensure the CMS-1500 and narrative report is forwarded in the correct format. If the bill is rejected by the payer, the clearinghouse must alert the medical provider.
  50. How long to remedy a rejected claim? If the bill is not acknowledged (rejected) by the payer, the clearinghouse and medical provider will have 7 days to correct the missing information and resubmit to the payer.
  51. If the claim is rejected can the claimant be billed? If the bill is rejected by the payer, it cannot be billed to the claimant. Section 13-f of the Workers’ Compensation Law prohibits providers from billing claimants.
  52. How will a claimant know of claim disputes? During Phase 1 & 2, the claimant will continue to receive C-8.1 objections from the payer.
  53. In the meeting dating back to Oct/Nov 2018, there was an issue with where the Carrier Received Date fit into the process. The requirement at that time was the Carrier Received Date went into effect when the XML Submission Partner received the bill. Has that changed? The “carrier received / acknowledgement date” will be the date in which the carrier accepts receipt of the bill.
  54. What if the payer does not acknowledge the bill or send to the Board? Carriers will be required to acknowledge the bill if it is received with all required information from the clearinghouse.
  55. So, in New York State, every workers’ comp carrier will have to pair with a clearinghouse? Workers’ compensation carriers will have to pair with a clearinghouse or multiple clearinghouses if they did not do so prior to Phase 2 of the initiative.
  56. Will we get a CPID# when we register to be able to submit the CMS-1500 electronically? Carriers will not receive a Claims Payer ID (CPID) number under this initiative.
  57. And if the patient was seen in a hospital, are there changes in the UB form? The CMS-1500 XML initiative will not apply to services billed by hospitals on the UB-04 form.
  58. The list of providers that is on the website seems to be only physicians. Will we as a hospital be able to submit the CMS-1500 electronically? Since hospital facility bills are not included in the CMS-1500 XML initiative, their bills will be able to be accepted at the Board by email or web-upload.

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