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Workers' Compensation Board

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CMS-1500 Requirements


All CMS-1500 submissions (whether submitted through an XML submission partner or sent directly to the Board) require a medical narrative and/or attachment.

CMS-1500 Field Matrix and Examples

Field Matrix

Examples


Medical Narrative Requirements


Attachment Requirements

CMS-1500 Required Attachments
Type of CMS-1500 Medical Bill Required Attachment
Psychology Psychology Narrative Report, including causation statement
DME Bill or invoice for the item(s) dispensed and a copy of the physician's prescription (order) for the item(s)
Pharmacy-Drugs Bill or invoice for the medication(s) dispensed and a copy of the physician's prescription (order) for the medication(s)
Radiology Bill or invoice for service and copy of radiologic report
Laboratory Bill or invoice for services and lab report (with the exception of UDT lab results, which by regulation can't be released to the Board, payer or employee)
PT/OT PT/OT Narrative Report containing diagnosis(es) from the referring physician/provider, relevant history, examination finding, assessment including specific impact of treatment on functional outcomes and plan of care, including specific objective functional goals.
Audiology Documentation of audiologic test battery results. (based on Record of Percentage Hearing Loss (Form C-72.1) adobe pdf )
Dental Detailed SOAP note reflecting history, exam, assessment and plan of care consistent with accepted dental documentation standards.
Optometry Detailed SOAP note reflecting history, exam, assessment and plan of care consistent with accepted optometry documentation standards.

Optional CMS-1500 Attachment: Physicians may include page 2 of the Doctor's Progress Report (Form C-4.2) adobe pdf, sections E and F as an optional attachment with the CMS-1500 and medical narrative to provide concise information on the Doctor's Opinion and Return to Work.


XML Submissions

Providers and XML submission partners will be required to follow specific technical processes and XML submission formats. Review the XML Forms Submission section of this website to obtain the detailed submission requirements. The CMS-1500 XML schema will be posted to the Board's website by July 23, 2018. The Board followed the National Uniform Claim Committee's (NUCC) July 2018 Instruction Manual for the CMS-1500 form.