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Workers’ Compensation Board

Medical and Billing Form Updates/Clarifications (02/05/20)

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.

As the NYS Workers’ Compensation Board works to integrate newly authorized providers into the New York State workers’ compensation system, there are some important clarifications to note regarding the use of the following medical and billing forms.

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

All medical providers are encouraged to use the CMS-1500 form (paper version) with an attached medical narrative report, but the current forms may continue to be used. Medical providers can submit supporting clinical documentation (which includes the required legal language regarding causation) on the medical narrative report and attach it to the CMS-1500 instead of using the current Board forms. (The Board has recently released a medical narrative template that should be used to create the medical narrative report.)

Use of Current Board Forms by Provider Type

Some of the current Board forms and XML submission of certain forms are permissible for certain provider types only, as shown in the chart below.

Provider Type Form/XML Usage
CMS-1500 plus NARR Board Forms XML
Physician Yes Form C-4, C-4.2, EC-4NARR EC-4NARR
Nurse Practitioner Yes Form C-4, C-4.2, EC-4NARR* EC-4NARR**
Physician Assistant Yes Form C-4.2, EC-4NARR* EC-4NARR**
Podiatrist Yes Form C-4, C-4.2, EC-4NARR EC-4NARR
Chiropractor Yes Form C-4, C-4.2, EC-4NARR EC-4NARR
Psychologist Yes Form PS-4, EC-4NARR EC-4NARR
Licensed Clinical Social Worker Yes Form EC-4NARR* EC-4NARR**
Physical Therapist Yes Form OT/PT-4, EOT/PT-4 EOT/PT-4
Occupational Therapist Yes Form OT/PT-4, EOT/PT-4 EOT/PT-4
Acupuncturist Yes N/A NONE

* To receive updates about availability of online form submission, sign up for WCB Notifications.

** To receive updates about availability of XML submission, sign up for WCB Notifications.



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 Form C-4 AUTH/MG-2 Permanency Opinions
Physician Form C-4 AUTH/MG-2 Form C-4.3
Nurse Practitioner Form C-4 AUTH/MG-2 Form C-4.3
Physician Assistant N/A N/A
Podiatrist Form C-4 AUTH/MG-2 Form C-4.3
Chiropractor Form C-4 AUTH/MG-2 Form C-4.3
Psychologist Form C-4 AUTH Form C-4.3
Licensed Clinical Social Worker Form C-4 AUTH Form C-4.3
Physical Therapist Form C-4 AUTH N/A
Occupational Therapist Form C-4 AUTH N/A
Acupuncturist Form C-4 AUTH N/A

Nurse Practitioner Authorization Numbers

While Nurse Practitioners (NPs) are among those providers who can use Form MG-2 to request a variance from the Medical Treatment Guidelines, the space on the form for authorization numbers is formatted differently than the actual NP authorization number. An NP may enter his or her authorization number into Form MG-2 even though the formatting is different. This is not a defect in Form MG-2, and the Form MG-2 should be processed to evaluate the medical necessity for the treatment requested.

Example:

NP’s authorization number: N987654-3
Formatted for Form MG-2: N98765-43

Individual Provider's WCB Authorization No.: N98765-43

More Information

For more information and resources related to the Expanded Provider Legislation, please visit the New Provider web page.

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