Revision to Subject Number 046-1362R2, released on February 23, 2022
March 30, 2022
The Board has made a number of important updates regarding the Notice of Treatment Issue/Disputed Bill (Form C-8.1) and Notice to Health Care Provider and Injured Worker of a Carrier's Refusal to Pay All (or a Portion of) a Medical Bill Due to Valuation Objection(s) (Form C-8.4). These updates, detailed below, include a change to the reporting of Social Security numbers and revisions to support the Board's transition to the universal billing form, the CMS-1500. The Board will be issuing new versions of the C-8.1 and C-8.4 forms in July and is restating the payer implementation schedule related to the CMS-1500 initiative.
Social Security Numbers
After a review of the C-8.1 and C-8.4 forms, the Board determined it would no longer require inclusion of an injured worker's full nine-digit Social Security number, as of June 16, 2021. Instead, only the last four digits of the Social Security number should be included on the forms. Payers completing the paper or online version of these forms should provide only the last four digits of the injured worker's Social Security number.
The C-8.1 and C-8.4 forms have been updated to clarify potential objections and to eliminate Part A Notice of Objection Regarding Further or Future Treatment on Form C-8.1. The objection reason "Requested treatment is not for an established site or condition," will be moved to the Request for Further Action by Insurer/Employer (Form RFA-2); a new version of Form RFA-2 will be published on May 2, 2022.
Form C-8.1 will be renamed Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B). Form C-8.4 will be renamed Notice to Health Care Provider and Claimant of an Insurer's Refusal to Pay All (or a portion) of a Medical Bill Due to Valuation Objection(s).
The new C-8.1B and C-8.4 forms will be implemented July 1, 2022, and will become mandatory 45 days later on August 15, 2022. At that point, the current versions of the forms will not be accepted, and no action will be taken by the Board should a payer continue to use them.
Effective October 1, 2021, payers were required to:
- Have one or more Board-approved XML submission partners designated to electronically accept health care provider medical bills via Electronic Data Interchange (EDI) or another format agreed upon with the XML submission partner.
Effective November 1, 2021, payers were required to:
- Identify all legal and valuation objections to payment of the medical bill at the same time and file such objections using the current versions of the C-8.1 and C-8.4 forms, within 45 calendar days of acknowledgement of receipt of the medical bill (whether on paper or digital). If the Form C-8.4 is submitted before the Form C-8.1B, the legal objections on Form C-8.1B will not be considered timely. If Form C-8.4 is submitted after Form C-8.1B, the valuation objections will not be addressed.
Effective July 1, 2022, payers must:
- Use the updated C-8.1B and C-8.4 forms (version 7/22) to notify the Board of legal and valuation objections, respectively.
- Use standardized objection reasons, also known as Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs), on an Explanation of Benefits/Explanation of Review (EOB/EOR) sent to a health care provider to object to payment of a medical bill. The payer must send the Board (and other required stakeholders) a timely filed Form C-8.1B or Form C-8.4 with the same objection reason(s) noted to properly object to such payment. All objections must be made at the same time. The new forms have been updated to include the associated CARC and RARC codes. RARC and CARC codes with associated objection reasons can be found on the Timeline section of the Board's CMS-1500 page.
Payer Objection Period: As a reminder, payers must remit payment or object to payment of a medical bill within 45 calendar days from when the bill is received. The acknowledgement date transmitted by the payer to the XML submission partner and also displayed on the CMS-1500 form (field 19) is the start date for the 45-day period. If the bill is not submitted electronically, the 45-day period will start on the date the bill was received by the Board.
Payer Notice to Providers: Payers have the option of sharing the C-8.1B and C-8.4 forms with providers by offering secure online access to their systems. However, if they choose to do so, they must notify providers via email each time documents are available to be downloaded or viewed. Such emailed notifications must include:
- Payer's name
- Injured worker's name
- WCB case number
- Injured worker's date of birth
- Date of medical service
- Date of EOB
- Provider's name
- Provider's NPI
- Bill amount
Payers who create a computer-generated Form C-8.1B or Form C-8.4 may email email@example.com to request a copy and to verify bar codes prior to the July 2022 implementation.
Questions regarding the CMS-1500 requirements, should be sent to CMS1500@wcb.ny.gov.
Clarissa M. Rodriguez