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Subject Number 046-1452 CMS-1500 Initiative Update for Payers

Board Bulletins and Subject Numbers

Updates Subject Number 046-1418, CMS-1500 Initiative Update for Payers, Published June 14, 2021

Date: September 29, 2021

The Chair would like to remind payers that a number of requirements related to the Board's initiative to transition to the universal billing form, Form CMS-1500, take effect next month, while others have been updated to coincide with the launch of OnBoard: Limited Release, the first phase of the Board's new business information system. The payer requirements are explained below.

Effective October 1, 2021, payers are required to:

Electronically accept Form CMS-1500
The electronic process prescribed by the Chair will require payers to partner with at least one Board-approved XML submission partner to transmit and accept health care provider medical bills via Electronic Data Interchange (EDI) or another format agreed upon with the XML submission partner. Right now, health care 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 that when using an XML submission partner, health care providers will not transmit medical bills directly to the Board. The XML submission partner will do so on their behalf.

XML submission partner(s) must be designated by October 30, 2021
Payers must designate at least one XML submission partner from whom they will accept medical bills with the Board. Payers must keep XML submission partner information accurate and update the online system within three (3) business days of any changes. 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.

Payers' Medical Portal Online Administrators will be able to use the online administrator application beginning October 1, to designate their XML submission partner(s). Directions for designating an XML submission partner are on the Board's website.

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 by the payer is referred to as the acknowledgement date. Medical bills electronically routed through a Preferred Provider Organization (PPO) prior to the payer are deemed acknowledged on the date accepted by the PPO. The XML submission partner will forward such acknowledgements to health care providers. The acknowledgements will be incorporated into the XML files that the XML submission partner sends 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 a 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 health care provider's XML 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. Payers must submit an EOB/EOR to their XML submission partner upon adjudication of the associated electronic CMS-1500 medical bills. The XML submission partner will forward the EOB/EOR to the health care provider. Pursuant to 12 NYCRR 325-1.25, payers must identify the objection reasons for non-payment on the EOB/EOR.

Effective November 1, 2021, payers are required to:

Identify all legal and valuation objections to payment of the medical bill and submit them at the same time on the same EOB/EOR
Payers will be required to make such objections within 45 calendar days of acknowledgement of receipt of the medical bill (whether on paper or digital). The payer must also continue to file such objections with the Board using the current versions of 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, also within 45 calendar days of acknowledgement of receipt of the medical bill (whether on paper or digital).

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 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