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Workers' Compensation Board

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New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
328 State Street  Schenectady, New York 12305
Governor Andrew M. Cuomo


Subject No. 046-1079

Board Announces Technical Specifications
for CMS-1500 Initiative

Date: July 16, 2018

As announced on April 17, 2018, in Subject Number 046-1058 Proposals to Improve Medical Care for Injured Workers, the New York State Workers' Compensation Board (Board) will replace the current Board treatment forms: Doctor's Initial Report (Form C-4), Doctor's Progress Report (Form C-4.2), Occupational/Physical Therapist's Report (Form OT/PT-4), Psychologist's Report (Form PS-4), and Ancillary Medical Report (Form C-AMR) with the CMS-1500 to help reduce paperwork and lower provider administrative burdens. This initiative will leverage providers' current medical billing software and medical records while promoting a more efficient workers' compensation system. It is expected that the initiative will roll out in three phases, as follows:

Phase 1: Commencing January 1, 2019:

  • Providers may voluntarily transmit CMS-1500 medical bills (and required medical narratives, and/or attachments as applicable) through an approved XML Submission Partner ("clearinghouse") to workers' compensation insurers/payers. Guidance on required medical narratives and attachments is available on the Board's website. As previously conveyed in Subject Number 046-785, if a CMS-1500 is submitted without the detailed narrative report or office note, it is not a valid bill submission. A listing of approved clearinghouses for the CMS-1500 will be posted on the XML Forms Submission section of the Board's website after each entity successfully completes testing and executes an XML Submission Partner agreement with the Board.
  • Workers' compensation insurers/payers will accept CMS-1500 medical billing files from clearinghouses and electronically return acknowledgments of receipt of CMS-1500 files. Such acknowledgements (including receipt date) will be forwarded from the clearinghouses back to providers and the Board.
  • The Board will receive CMS-1500 files, narrative attachments and acknowledgements of receipt from clearinghouses in a designated XML format. The CMS-1500 forms and narrative attachments will be combined and displayed in the applicable claimants WCB case folders.

Phase 2: On or about July 1, 2019:

  • Workers' compensation insurers/payers will electronically transmit Explanations of Benefits (EOB) to their clearinghouses upon adjudication of the associated electronic CMS-1500 medical bills. Such EOB data will be forwarded from the clearinghouses back to providers and the Board.
  • The Board will receive EOB data from clearinghouses in a designated XML format.
  • The Board plans to eliminate the requirement for the insurer/payer to file Form C-8.1B or C-8.4 form (to object to full or partial payment of a medical bill) when an EOB for the medical bill was transmitted through the clearinghouse and the Provider may file Health Provider's Request for Decision on Unpaid Medical Billing (Form HP-1) (based on receipt of EOB).

Phase 3: On or about January 1, 2020:

  • Providers will be required to submit electronic CMS-1500 medical bills (and required medical narratives, as applicable) through their clearinghouses to workers' compensation insurers/payers and to receive EOBs back through their clearinghouse.
  • Providers will be required to electronically transmit any disputes for unpaid medical bills to their clearinghouse using the Board-prescribed form. The clearinghouses will electronically transmit medical disputes to the Board in a designated XML format. The Board will eliminate Forms C-4, EC-4, C-4.2, EC-4.2, C-4.1, PS-4, C-4AMR, EC-4AMR, OT/PT-4, EOT/PT4 and EC-4NARR forms. Web submission and XML submission of these forms will no longer be available.
  • The Board will establish a hardship exception process for providers who are unable to meet the mandatory electronic reporting requirements.

Visit the CMS-1500 Initiative section of the website to access technical specifications for the CMS-1500 medical billing and associated acknowledgement data and to find periodic updates.

Please direct questions to CMS1500@wcb.ny.gov.

 

Clarissa M. Rodriguez
Chair