What Providers Need to Know - Archived Updates

September 28, 2021

Updates to Medical Treatment Guidelines

Board Chair Clarissa M. Rodriguez has adopted amendments to 12 NYCRR 324.2 to incorporate updates to the New York Medical Treatment Guidelines (MTGs)

• New York Mid and Low Back Injury (updated)
• New York Neck Injury (updated)
• New York Knee Injury (updated)
• New York Shoulder Injury (updated)
• New York Post-Traumatic Stress Disorder and Acute Stress Disorder (NEW!)
• New York Work-Related Depression and Depressive Disorders (formerly referred to as Major Depressive Disorder) (NEW!)
• New York Non-Acute Pain (updated)

You can access full details on the amendments, including a PDF of the respective MTGs, via Subject Number 046-1441, Subject Number 046-1442, and Subject Number 046-1443.

Training Available!

As a reminder, the Board recently launched online training on the newly adopted and updated MTGs. Each training, accessible on the Board's website, provides an overview of the General Guideline Principles, diagnoses associated with the body part or condition, as well as diagnostic and treatment recommendations.

As an added benefit, there is opportunity to obtain up to three complementary continuing medical education (CME) credits upon completion of each course. For those on your staff who would benefit from the training but do not need CME credit, non-CME versions of the presentations are available.

To register for the training courses and receive CME credits, go to MTG Training for CME Credit.

For the non-CME training, go to Training for Non-medical and Administrative Staff.

CMS-1500 Transition Updates

To reduce the administrative burden on Board-authorized health care providers, the Board made the strategic decision to consolidate and eliminate certain medical billing forms and transition to using Form CMS-1500. The following timeline for this transition has recently been updated.

• Phase 1: Voluntary submission (happening now)

  Board-authorized providers may voluntarily transmit CMS-1500 medical bills (and required medical narratives, and/or attachments as applicable) via mail, email, web upload and XML; however, it is recommended that it is done electronically through one of the approved XML submission partners (most commonly known as 'clearinghouses').

• Phase 2: Payers mandated to accept electronic medical bills and Explanation of Benefit / Explanation of Review (EOB/EOR) transmittal (October 1, 2021)

  Payers must electronically accept Form CMS-1500 (can be EDI or other agreed upon format). Payers will electronically transmit EOBs/EORs to their XML submission partners upon adjudication of the associated electronic Form CMS-1500 medical bills.

• Effective November 1, 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).

• Phase 3: Mandatory submission of Form CMS-1500 by providers and payer use of specific Claims Adjustment Reason Codes (CARCs) (July 1, 2022)

  Beginning July 1, 2022, the use of Form CMS-1500 will be mandatory, and electronic submission through a clearinghouse will be strongly encouraged, although not required. Payers will be required to use specific Claims Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) on their provider EOBs/EORs when objecting to payment of a medical bill.

For more information, visit the CMS-1500 page or email CMS1500@wcb.ny.gov.

Reminder: CMS-1500 Medical Narrative Template & Requirements

The Board has developed a medical narrative report template that can be used to create the medical narrative report that accompanies provider submissions of Form CMS-1500.

The template includes at the top of the page the three mandatory elements to include with most narratives:

1. the patient's work status,
2. causal relationship of the injury to the patient's work activities, and
3. temporary impairment percentage.

A medical narrative report may be found legally defective if these elements are missing.

When the medical narrative template is used, providers must attach a narrative report with examination findings, including:

• the history of the injury/illness,
• any objective findings based on the clinical evaluation,
• plan of care, and
• the diagnosis(es)/assessment of the patient.

In lieu of using the template, the provider's own medical narrative report is acceptable, if it includes and prominently displays:

• work status,
• causal relationship, and
• temporary impairment percentage.

For more information, visit the CMS-1500 page or email CMS1500@wcb.ny.gov.

Drug Formulary Update and Medical Marijuana Clarification

Regulations regarding the New York Workers' Compensation Drug Formulary (Formulary) that were adopted by Chair Clarissa M. Rodriguez and published in the September 1, 2021, State Register will be deferred from September 1, 2021, and will coincide with the launch of OnBoard: Limited Release, the first phase of the Board's new business information system. Those regulations include the following:

• The updated Formulary drug list;
• A new effective date for compliance with the Formulary for refills and renewals (previously delayed during the COVID-19 pandemic); and
• Clarification that a medical marijuana prior authorization request (PAR) will no longer be submitted via the existing variance request process but will instead be submitted within OnBoard: Limited Release as a "Medication PAR" (although the criteria needed for approval will remain the same)

The Board is committed to giving stakeholders a four-week notification of the implementation date of OnBoard: Limited Release.

Visit the Board's website for more information about the Formulary.

Provider Registration and Delegate Assignment Continues for OnBoard: Limited Release

While we prepare for the Board's new business information system, OnBoard, and its early component OnBoard: Limited Release, the Board continues to encourage health care providers to register and assign delegates in preparation for the launch of our new system.

Health care providers must use the Medical Portal to access OnBoard: Limited Release (or to apply for Board authorization, or to renew their registration with the Board) which requires an NY.gov user ID and password for access.

The updated Medical Portal section of the website contains all of the details and information you need regarding how to register and get an NY.gov user ID and password (and grant access to others to act as your delegate) to access OnBoard: Limited Release.

Assigning delegates now will benefit you when OnBoard: Limited Release launches, as delegates can assist you by:

• Drafting prior authorization requests (PARs), which must be reviewed and submitted by the health care provider.
• Drafting escalations to Level 2 Medication PARs, which must be reviewed and submitted by the health care provider.
• Drafting PAR escalations to Level 3 for Medical Director's Office review.
• Responding to insurer requests for information.
• Drafting and submitting Request for Decision on Unpaid Medical Bills (Form HP-1.0).

For additional information, including a walkthrough of the registration process, you can view a video tutorial, check out the provider registration guide or view a recording of the May 11, 2021 webinar for health care providers. You can also view an OnBoard: Limited Release fact sheet and FAQs for providers. Questions? Write to onboard@wcb.ny.gov.

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