WHAT PAYERS NEED TO KNOW - ARCHIVED UPDATES
August 28, 2025
Electronic CMS-1500 mandate now in effect
As of August 1, 2025, all treating healthcare providers in the workers' compensation system are required to submit the CMS-1500 universal billing form electronically, through a Board-approved electronic submission partner, in order to be paid for services.
Read more in a notification dated August 13, 2025.
If payers receive a paper CMS-1500 bill on or after August 1, 2025, do not submit a Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B). Instead, you are instructed to issue the provider an Explanation of Benefits / Explanation of Reimbursement (EOB/EOR) that references CARC 16/RARC N34 codes, to indicate the provider's bill was not submitted electronically. In order to be reimbursed, providers must resubmit any denied bills to payers electronically through an approved electronic submission partner within 120 days from the date medical care was rendered.
Read more in a notification dated July 8, 2025.
Payment of CPT code 99080 on CMS-1500 bills
Payers are instructed to remit payment for the 99080 charge on CMS-1500 bills. Additionally, they are advised not to submit objections to CMS-1500 forms - whether through Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B) or Notice to Health Care Provider and Claimant of an Insurer's Refusal to Pay All (or a portion) of a Medical Bill Due to Valuation Objection(s) (Form C-8.4) - when the only basis for the objection is the inclusion of CPT code 99080 with an amount of $1.00 or less.
Read more in a notification dated June 30, 2025.
New inpatient rates for acute per case inpatient rates, exempt hospitals, exempt units, and chemical dependency detoxification rates, effective January 1, 2025
The NYS Office of Health Insurance Programs has calculated rates of reimbursement for the period January 1, 2025, through December 31, 2025, for acute per case, exempt hospital, exempt unit, and chemical dependency detoxification services.
Read more in a Subject Number 046-1773.
Efficiency Enhancements: form updates
The Board recently updated two forms that allow parties to enter into stipulations to resolve issues that are in dispute. The Stipulation (Form C-300.5) and Agreed Upon Findings and Awards for Proposed Conciliation Decision (Form C-312.5) now require parties to indicate whether a fee is payable to prior counsel who was discharged by the claimant. The Form C-312.5 now requires parties to indicate whether there is a pending application for administrative review that will be withdrawn upon approval of the stipulation. These changes avoid the need for the Board to contact parties for clarification and/or to submit an amended Form C-300.5 or Form C-312.5, enabling faster review and approval of stipulations.
Read more in a notification dated August 1, 2025.
ICYMI: Subject Number 046-1766, network pharmacies and notice requirements
The Chair has adopted the amendments to Sections 440.3, 440.4, and 441.3 of 12 NYCRR to provide a path for claimants to obtain medically necessary medication either through use of a network pharmacy or by notice of their ability to use an out-of-network pharmacy.
Read more in a notification dated June 30, 2025.
Submission of Employee Claim (Form C-3) at pre-hearing conference
The Employee Claim (Form C-3) is now eligible for eCase document upload for claimants and claimant attorneys. In cases with a notice of controversy, if a represented claimant has not filed a Form C-3 with the Board prior to the pre-hearing conference, the claimant and their representative are required to complete a Form C-3 and file it with the Board via eCase document upload at the pre-hearing conference (see 12 NYCRR 300.33[f][6] and 300.38[g][6]).
Read more in a notification dated June 3, 2025.
Residents and fellows permitted to treat workers' compensation patients
As part of Governor Kathy Hochul's Fiscal Year 2026 Budget signed into law on May 9, 2025, effective immediately, physicians who are training in residency and fellowship programs accredited by the Accreditation Council on Graduate Medical Education (ACGME) are permitted to treat injured workers in New York State under the appropriate supervision of faculty physicians (see Workers' Compensation Law Section 13-b[2][b-2]). A new Welcome page for residents and fellows is available on the Board's website that provides more information.
New maximum weekly benefit rate effective July 1, 2025.
The maximum weekly benefit rate for workers' compensation claimants is two-thirds of the New York State Average Weekly Wage for the previous calendar year, as determined by the New York State Department of Labor (Workers' Compensation Law ยงยง 2[16] and 15[6]).
Read more in Subject Number 046-1754.
Reminders
Telehealth is now a permanent option in the workers' compensation system. Read more in Subject Number 046-1613.
The What Payers Need to Know section of the Board's website walks payers through getting started in the workers' compensation system, becoming a trading partner, administering claims, and more.
Use of the CMS-1500 form is mandatory. Visit CMS-1500 initiative for more details and send your questions to CMS1500@wcb.ny.gov.
Visit the Board's website for OnBoard training guides, webinar recordings, and other resources.
Efficiency Enhancements is a new communication with tips and best practices on using Board systems, processes, and forms in the most efficient, effective manner. Sign up to receive these, and other updates, straight to your inbox.
The latest versions of several Paid Family Leave presentations are available, including family care, foster care/adoption, military leave, and bonding. Visit the Paid Family Leave website for more information.
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