Skip to Content

Workers' Compensation Board

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


CMS-1500 Examples


Medical Billing Forms Crosswalk


Medical Narrative Requirements


Attachment Requirements

CMS-1500 Required Attachments
Type of CMS-1500 Medical Bill Required Attachment
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)
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.
Anesthesia Anesthesia record indicating the exact time the anesthesia services were started, ended, all of the anesthesia team members who participated in the care, surgeon, procedure, patient vital signs, etc.

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 Board followed the National Uniform Claim Committee's (NUCC) July 2018 Instruction Manual for the CMS-1500 form.