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Important Update on Workers' Compensation Board Operations (June 2021)

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Subject Number 046-1418 CMS-1500 Initiative Update for Payers

Board Bulletins and Subject Numbers

Revised to update implementation dates

Date: June 14, 2021

As part of the Board's initiative to transition to the universal billing form, Form CMS-1500, the Board has updated payer requirements and adjusted the implementation schedule. The payer requirements, which go into effect October 1, 2021, and July 1, 2022, are explained below.

Effective October 1, 2021:

Have a Designated Board-Approved XML Submission Partner

The electronic process prescribed by the Chair will require payers to partner with at least one Board-approved XML submission partner to electronically transmit and accept health care provider medical bills (this must be done via Electronic Data Interchange (EDI) or another format agreed upon with the XML submission partner). Right now, providers may voluntarily submit Form CMS-1500 to many payers through an XML submission partner. As of October 1, 2021, although electronic submission will be optional for providers, all payers must accept electronic transmission of health care provider medical bills. It's important to note, when using an XML submission partner, providers will not transmit medical bills directly to the Board, the XML submission partner will do so on their behalf.

Note: The Board is currently developing the process for payers to designate the XML submission partner from whom they will accept medical bills and will communicate registration information once finalized. Payers must designate at least one XML submission partner. Payers must keep XML submission partner contact information accurate and notify the Board of any changes within three (3) business days. A listing of approved XML submission partners for the CMS-1500 initiative is posted on the XML Forms Submission section of the Board's website and is updated after each entity successfully completes testing and executes an XML submission partner agreement with the Board.

Acknowledge Medical Bills within Seven (7) Business Days

Payers must accept an electronic medical bill from an XML submission partner when it is transmitted using EDI or another format agreed upon with the XML submission partner. The date the medical bill is accepted is referred to as the acknowledgement date. Such acknowledgements will be forwarded from the XML submission partner back to health care providers and will be incorporated in the XML files sent by the XML submission partner to the Board. As a reminder, receipt of a medical bill (whether on paper or digital) is considered notice of a potential claim. Thus, insurers must investigate existence of a claim if one has not yet been filed. Medical bills should not be rejected solely due to lack of a claim on file.

Note: The only basis for a payer to reject an electronic bill from the designated XML submission partner is if a mandatory field is incomplete or the insurer does not provide coverage to the employer. A rejection of an electronic bill must be made within seven business days of the bill's initial transmission date from the medical provider's submission partner. Mandatory fields can be found in the Board's CMS-1500 Field XML Schema. Column D indicates whether the data is required, situational or optional.

Submit an Electronic Explanation of Benefits/Explanation of Review (EOB/EOR)

The EOB/EOR is the Board-prescribed format for filing an objection(s) to the payment of a medical bill. Insurers must submit an EOB/EOR to their XML submission partner upon adjudication of the associated electronic CMS-1500 medical bills. The EOB/EOR will be forwarded from the XML submission partner back to health care providers. Pursuant to 12 NYCRR 325-1.25, payers must identify the objection reasons for non-payment on the EOB/EOR. All legal and valuation objections to payment of a medical bill must be made at the same time and on the same EOB/EOR. Such objections must be made within 45 calendar days of acknowledgement of receipt of the medical bill (whether on paper or digital). The payer should continue to send the Board the Notice of Treatment Issue/Disputed Bill (Form C-8.1) and/or 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), along with a copy of the EOB/EOR to object to payment of a bill.

Effective July 1, 2022:

Form CMS-1500 Submission & Claims Adjustment Reason Codes

Effective July 1, 2022, health care providers will be required to utilize Form CMS-1500 to properly bill for workers' compensation related services. Electronic submission is strongly encouraged. Payers will be required to utilize the appropriate Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) on an EOB/EOR sent to a health care provider to object to payment of a medical bill. RARC and CARC codes with associated objection reasons can be found on the Timeline section of the Board's CMS-1500 page.

Questions related to this announcement can be sent to CMS1500@wcb.ny.gov.

Clarissa M. Rodriguez
Chair