All health care providers who would like to submit the CMS-1500 using the XML submission process must first complete the online Medical Portal registration.
After logging into the Medical Portal, providers who have not already signed up for XML submission of the CMS-1500 will see a link under the Billing section "Agreement for XML submission of CMS-1500." Select the link and click the "I Accept" button. The provider's name will be added to the Listing of Providers Authorized to Submit XML Data (MS Excel), which is updated daily. Once accepted, the link will no longer appear on subsequent logins.
Note: The Board posts a list of approved XML submission partners and their contact information to assist providers in locating an XML submission partner who can submit CMS-1500 files on their behalf.
When a CMS-1500 is submitted to the Board using the XML submission process, it is the XML submission partner's responsibility to submit the form and narrative attachment to the Board. Providers SHOULD NOT mail, fax or email a duplicate paper form to the Board.
The electronic process, prescribed by the Chair, requires payers to partner with at least one Board-approved XML submission partner to transmit and accept health care provider medical bills via Electronic Data Exchange (EDI), or another format agreed upon with the XML submission partner, by October 1, 2021.
Payers must designate with the Board the XML submission partner(s) from whom they will accept medical bills by October 30, 2021. The payers' Medical Portal Online Administrators must keep XML submission partner information accurate and update the online administrator application with any changes within three (3) business days. Detailed instructions on updating XML submission partner designations can be found on the Designating an XML Submission Partner page.
A list of approved XML submission partners for the CMS-1500 is posted on the XML Forms Submission section of the Board's website and is updated after each entity successfully completes testing and executes an XML Submission Partner Agreement with the Board.
Please contact the WCB Customer Support Unit if you have technical questions regarding adding an XML submission partner.
Workers' compensation payers will electronically transmit Explanation of Benefits/Explanation of Reviews (EOBs/EORs) to their XML submission partners upon adjudication of the associated electronic CMS-1500 medical bills. The electronic EOBs/EORs may be in the X12 835 EDI standard or any other mutually agreed-upon data file format. Such EOB/EOR data will be forwarded from the XML submission partner back to the provider.
Payers are required to use specific Claims Adjustment Reason Codes (CARC) on their provider EOBs/EORs when objecting to payment of a medical bill whether the bills are received through an XML submission partner or on paper. Listing of CARCs and additional guidance: Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs). The provider may file Health Provider's Request for Decision on Unpaid Medical Billing (Form HP-1.0) based on receipt of the EOB/EOR with required CARC codes. The new Notice of Objection to a Payment of a Bill for Treatment Provided (C-8.1B) and Notice to Health Care Provider and Claimant of an Insurer's Refusal to Pay All (or a portion) of a Medical Bill Due to Valuation Objection(s) (C-8.4) forms, as well as the payers' use of specific CARCs implemented July 1, 2022, will become mandatory on September 19, 2022. At that point, the current versions of the forms will not be accepted, and no action will be taken by the Board should a payer continue to use them.
Additionally, payers are required to identify all legal and valuation objections to payment of the medical bill at the same time and file such objections by paper or electronically using Forms C-8.1B or C-8.4 within 45 calendar days of acknowledgement of receipt of the medical bill. See Subject Number 046-1465 Adoption of Amendment to 12 NYCRR 325-1.25 (Medical Billing Disputes).
XML Submission Partners
All XML submission partners must execute a Test Agreement for Business Partners Submitting Medical Reports in XML Format, successfully complete CMS-1500 XML testing and execute a new XML Submission Partner's Agreement for XML Submission of CMS-1500 Forms and Medical Narrative Reports on Behalf of Health Care Provider with the Board. Clearinghouses interested in becoming an XML submission partner will need to register first with the Board.
The Board will accept the CMS-1500 form, medical narrative and/or attachments, and acknowledgment receipts from payers, using the Board's specific XML form submission process. XML submission partners may also be required to submit reporting metrics to the Board documenting the efficiency of form submission to the payer. The XML submission partners will be required to submit CMS-1500 and narrative reports to the Board within seven business days of receipt from the provider. When a CMS-1500 and narrative report are not accepted by the payer within three business days, the XML submission partner will be required to advise the provider and seek direction as to whether to continue electronic submission attempts or submit the CMS-1500 and narrative report in paper format. The reporting requirements of the Workers' Compensation Law and its regulations, specifically 12 NYCRR §325-1.3, remain unchanged. Providers (and XML submission partners on behalf of providers) are required to remain compliant with these reporting requirements.