Workers' Compensation Resources for Claims Administrators
In order to increase health care provider participation in the workers' compensation system and improve injured workers' access to timely, quality medical care, the Workers' Compensation Board (Board) made a strategic decision to transition toward making the CMS-1500 a required form.
Providers have indicated that the unique paperwork requirements currently in the workers' compensation system are time consuming to complete. To reduce the administrative burden and increase provider participation, the Board will consolidate and eliminate certain medical billing forms and convert to the CMS-1500, the universal claim form used by medical providers to bill the Centers for Medicare and Medicaid Services (CMS) as well as health insurers.
The initiative will leverage providers' current medical billing software and medical records while promoting a more efficient workers' compensation system.
The Board replaced the following forms with the CMS-1500:
- 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)
The CMS-1500 must be submitted with a detailed narrative report to be considered a valid submission The Board has developed a template that providers can use to create the medical narrative report that accompanies provider submissions of the CMS-1500. A sample of the template can be found on the CMS-1500 Requirements page.
CMS-1500 Submission Process
- Providers are strongly encouraged to partner with an XML submission partner who will ensure that the medical bill and narrative attachment are sent and accepted by the correct payer. However, "paper" CMS-1500 submissions are permitted and can be submitted by mail, email or web upload.
- If partnered with a clearinghouse (XML submission partner), providers do not need to complete a CMS-1500 form but rather submit their bill and narrative attachment to the XML submission partner they have a relationship with in the agreed-upon format.
- The XML submission partner will forward the bill and narrative attachment to the workers' compensation payer.
- The payer will accept the CMS-1500 from the XML submission partner and return electronic acknowledgement of receipt.
- The XML submission partner will forward the acknowledgement, including receipt date, to the provider.
- XML submission partners will transmit, in the designated XML format, the billing data (including the payer's acknowledgement of receipt), the CMS-1500 forms and narrative attachments, and payers' acknowledgements of receipt to the Board. The CMS-1500 forms and narrative attachments received by the Board will be combined and displayed in the applicable injured workers' WCB case folders.
When CMS-1500 forms are submitted to the Board using the XML submission process, providers SHOULD NOT mail, fax or email a duplicate paper form to the Board.
Payers’ XML Submission Partner Designation
The electronic process, prescribed by the Chair, requires payers to partner with at least one Board-approved XML submission partner to transmit and accept health care provider medical bills via Electronic Data Exchange (EDI), or another format agreed upon with the XML submission partner, by October 1, 2021.
Payers must designate with the Board, the XML submission partner(s) from whom they will accept medical bills by October 30, 2021. The payers' Medical Portal Online Administrators must keep XML submission partner information accurate and update the online administrator application with any changes within three (3) business days.
A list of approved XML submission partners for the CMS-1500 is posted on the XML Forms Submission section of the Board's website and is updated after an entity successfully completes testing and executes an XML Submission Partner Agreement with the Board.
Please contact the WCB Online Services Technical Support Unit if you have technical questions regarding adding a XML submission partner.
Resources
- Subject Number 046-1362R3 – Important Updates Regarding Forms C-8.1 and C-8.4, Including Implementation Dates Related to the CMS-1500 Initiative
- Requirements
- Payers FAQs
- XML Submission Partners
- Questions can be directed to: CMS1500@wcb.ny.gov
- View a video presentation for providers on CMS-1500 and the Expanded Provider Law.