The initiative is rolling out in three phases, as follows:
Phase 1 – Voluntary Submission (Current Phase)
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 Form CMS-1500 forms using an XML submission partner must first complete the online Medical Portal registration process. Next, providers 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.
- XML submission partners interested in submitting to the Board must also register by contacting the Board. All XML submission partners (both existing and new) must successfully complete testing with the Board to obtain approval to submit the CMS-1500 in XML format. A listing of approved XML submission partners for the CMS-1500 can be found on the Board's website.
- Many Workers' compensation payers will accept Form CMS-1500 medical billing files from XML submission partners (can be EDI or other agreed upon format) and electronically return acknowledgments of receipt of Form CMS-1500 files. Such acknowledgments (including receipt date) will be forwarded from the XML submission partners back to providers and the Board.
- The Board will receive CMS-1500 files, 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.
- The XML submission partners will be required to be submit CMS-1500 and narrative reports to the Board within seven business days of receipt from the provider. When a CMS-1500 form and narrative report is 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.
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, payers must electronically accept Form CMS-1500 (can be EDI or other agreed upon format). Workers' compensation payers will accept CMS-1500 medical billing files from XML submission partners and electronically return acknowledgements of receipt of these bills to the XML submission partners (who will share the acknowledgement with providers). The CMS-1500 medical billing files, including the payer's acknowledgement date, will be forwarded by the XML submission partners to the Board.
Additionally, 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 on Forms C-8.1 and C-8.4 within 45 calendar days of acknowledgement of receipt of the medical bill (whether on paper or digital). See Subject Number 046-1420 Proposed Amendment of 12 NYCRR 325-1.25 (Medical Billing Disputes)
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 format. Such EOB/EOR data will be forwarded from the XML submission partners back to providers. During this phase, all payer objections must be filed at the same time on the C-8.1B (for legal objections) or the C-8.4 (for valuation objections).
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 Form CMS-1500 will be mandatory, and electronic submission through a clearinghouse 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. 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.