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Medical and Billing Form Updates/Clarifications (11/15/22)

As of January 1, 2020, licensed clinical social workers, nurse practitioners and acupuncturists, as well as physician assistants, occupational therapists and physical therapists can be authorized to treat injured workers in New York State. Going forward, only those providers who are Board authorized may treat workers’ compensation patients.

Beginning July 1, 2022, the use of the CMS-1500 will be mandatory, and electronic submission by providers through an XML submission partner will be strongly encouraged, although not required.

The Board will eliminate the following forms:

Web submission and XML submission of these forms will no longer be available.

The C-4.3 remains in full effect for permanency evaluations.

Terminology

Until the terminology on the forms can be amended, the terms “doctor” and “physician” should be read as “medical provider.”

CMS-1500 and Medical Narrative

On July 1, 2022, all medical providers will be required to use the CMS-1500 form (paper or electronic via XML) with an attached medical narrative report to be considered a valid submission. Medical providers should submit supporting clinical documentation (including causal relationship, temporary impairment and work status) on most medical narrative reports and attach it to the CMS-1500 instead of using the current Board forms. (The Board has recently released a medical narrative template that can be used to create the medical narrative report.)

It will become mandatory for all the provider types below to use the CMS-1500 form whether submitting by paper or XML. A chart outlining the legally required elements that providers may comment on, according to their specialty, can be found on the CMS-1500 Requirements page.

The Board’s forms for prior authorization requests and opinions on permanency are permissible for certain provider types only, as shown in the chart below.

Forms for Prior Authorization Requests & Opinions on Permanency

Provider Type Prior Authorization Requests (PARs) Permanency Opinions
Physician Medications, Confirmations, Variance, Special Service, DME, Non-MTG Over 1000, Non-MTG Under or = $1000 Form C-4.3*
Nurse Practitioner Medications, Confirmations, Variance, Special Service, DME, Non-MTG Over 1000, Non-MTG Under or = $1000 Form C-4.3*
Physician Assistant** Medications, Confirmations, Variance, DME, Non-MTG Over 1000, Non-MTG Under or = $1000 Form C-4.3*
Podiatrist Medications, Confirmations, Variance, Special Service, DME, Non-MTG Over 1000, Non-MTG Under or = $1000 Form C-4.3*
Chiropractor Confirmations, Variance, DME, Non-MTG Over 1000, Non-MTG Under or = $1000 Form C-4.3*
Psychologist Confirmations, Variance, Non-MTG Over 1000, Non-MTG Under or = $1000 Form C-4.3*
Licensed Clinical Social Worker Confirmations, Variance, Non-MTG Over 1000, Non-MTG Under or = $1000 Form C-4.3*
Physical Therapist Non-MTG Over 1,000, Non-MTG Under or = $1000 N/A
Occupational Therapist Non-MTG Over 1,000, Non-MTG Under or = $1000 N/A
Acupuncturist Non-MTG Over 1000, Non-MTG Under or = $1000 N/A

*The Form C-4.3 is not being replaced by the CMS-1500; however, the CMS-1500 form may be used to electronically submit medical bills for permanency evaluations using an XML submission partner. To do so, medical providers should: 1) Only use CPT codes 99243 or 99245; 2) Only use ONE CPT code (99243 or 99245) on the medical bill; 3) Attach a completed C-4.3 to the CMS-1500 form as the medical narrative; and 4) Do not separately send a C-4.3 to the Board.

**All Physician Assistant services must be performed under physician supervision.

To receive updates about availability of online forms and XML submissions, sign up for WCB Notifications.

More Information

For more information and resources related to the Expanded Provider Law, please visit the Expanded Provider Law web page. More information on the CMS-1500 initiative can be found on the CMS-1500 Initiative webpage.

If you have any questions about WCB medical and billing forms, please contact the Medical Director’s Office at WCBMedicalDirectorsOffice@wcb.ny.gov.