The initiative is rolling out in three phases, as follows:
Phase 1 – Voluntary Submission
The first XML submission partner was approved in February 2020. As additional XML submission partners are approved, they will be added to the List of approved XML Submission Partners.
- 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: insurers, third-party administrators or self-insured employers.
- The CMS-1500 must be submitted with a detailed narrative report to be considered a valid submission. Guidance on Required Medical Narratives and Attachments
- All health care providers who would like to submit the CMS-1500 using the XML submission process must first complete an online Medical Portal registration and then accept the terms of the legal agreement by selecting the "Agreement for XML submission of CMS-1500" found under the Billing section of the Medical Portal.
- Workers' compensation payers may accept CMS-1500 medical billing files from XML submission partners (can be EDI or other agreed-upon format) and electronically return acknowledgments of receipt. Acknowledgments (including receipt date) will be forwarded from the XML submission partners back to providers.
- 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.
- The Board will receive CMS-1500 forms, narrative attachments, and payers' acknowledgment of receipt directly from XML submission partners in a designated XML format. The CMS-1500 forms and narrative attachments received by the Board will be combined and displayed in the applicable claimants' WCB case folders.
Phase 2 – Mandatory Payer Acceptance of Electronic Billing and Explanation of Benefit / Explanation of Review (EOB/EOR) Transmittal (October 1, 2021)
Starting October 1, 2021, workers' compensation payers must electronically accept the CMS-1500 (can be EDI or other agreed-upon format) from the XML submission partner and return electronic acknowledgement of receipt.
Payers are required to have one or more Board-approved XML submission partners. Payers must designate with the Board the XML submission partner(s) from whom they will accept medical bills by October 30, 2021.
Workers' compensation payers will electronically transmit 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.
Additionally, effective November 1, 2021, payers will be 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-8.1 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).
Phase 3 – Mandatory Provider Submission of CMS-1500 and Payer Use of Specific Claims Adjustment Reason Codes (CARC) (July 1, 2022)
Beginning July 1, 2022 the use of the CMS-1500 will be mandatory, and electronic submission by providers through an XML submission partner will be strongly encouraged, although not required.
The Board will eliminate the following forms:
- Doctor's Initial Report (Forms C-4, EC-4)
- Continuation to Carrier/Employer Billing Section (Form C-4.1)
- Doctor's Progress Report (Forms C-4.2, EC-4.2)
- Ancillary Medical Report (Forms C-4AMR, EC-4AMR)
- Doctor's Narrative Report (Form EC-4NARR)
- Occupational/ Physical Therapist's Report (Forms OT/PT-4, EOT/PT-4)
- Psychologist's Report (Form PS-4)
- Ophthalmologist's Report (Form C-5)
Web submission and XML submission of these forms will no longer be available.
Phase 3 will require payers 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) based on receipt of the EOB/EOR with required CARC codes.