Attention Health Care Providers – CMS-1500 Updates

As you may be aware, the Workers’ Compensation Board (Board) is transitioning to using the CMS-1500 form to streamline the medical billing process and reduce the paperwork requirements currently in the workers’ compensation system. Read on for some important updates related to this initiative.

Registering for the Medical Portal

Health care providers are encouraged to sign up for the Medical Portal now so you may take advantage of all the online services the Board offers, including registering for electronic medical billing through an approved XML submission partner (also known as a clearinghouse).

You can view instructions for registering for the Medical Portal on the Board’s website.

NEW! XML Agreement Affirmation 

Health care providers must have an XML agreement on file with the Board to submit the CMS-1500 form through an approved XML submission partner. If no agreement is on file, bills submitted through an XML submission partner will be rejected.  

The Board has made it easy to accept the agreement.

1. When you sign in to the Medical Portal on the Board’s website, you will be brought to this page. In the Billing section on the right, you will see “Agreement for XML submission of CMS-1500”.

2. When you select “Agreement for XML submission of CMS-1500,” a message will pop up that looks like this:

3. Select the teal “I Accept” button at the bottom of the agreement. Once you accept the agreement, the link will no longer appear in the Billing section when you sign in again.

Reminder: Medical Narrative Report Template

The Board has developed a medical narrative report template that can be used to create the medical narrative report that accompanies a health care provider’s submission of the CMS-1500 form.

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

• the patient’s work status,
• causal relationship of the injury to the patient's work activities, and
• temporary impairment percentage.

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

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

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

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

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

Important: Effective Date Requirements

Beginning July 1, 2022, health care providers will need to:

• Submit the CMS-1500 form. Electronic submission through an XML submission partner is strongly encouraged, though not required. When mandatory submission of the CMS-1500 form begins, use of current medical billing/reports including Doctor’s Initial Report (Form C-4) and Doctor’s Progress Report (Form C-4.2) will be discontinued.
• Prominently report the injured worker’s temporary impairment percentage, work status and the causal relationship of the injury at the top of the CMS-1500 form medical narrative.

Between now and July 1, 2022 health care providers are urged to review their processes to understand how these changes will affect them. The Board will continue to post periodic updates to the website based on feedback and questions received from stakeholders.

OnBoard Project

In addition to the transition to CMS-1500, the Board is in the process of making other improvements, including developing a new business information system, OnBoard. OnBoard will be a Better System for a Better Board – providing an intuitive, user-friendly system, increased accuracy and quality, and paperless transactions to our system participants.

Since building a new, integrated system from the ground up takes time, we’re starting with some high-priority processes (including the prior authorization request processes and the submission of Request for Decision on Unpaid Medical Bill(s) [Form HP-1.0]), that will benefit from moving online in what we are referring to as OnBoard: Limited Release.

Although an implementation date is still being determined, the Board is committed to providing at least four weeks advance notice before OnBoard launches – including training announcements. Visit the Board’s OnBoard webpage to learn more and stay engaged as this project progresses.

Additional Resources

You can visit the Board’s website for CMS-1500 news, FAQs, and more. The Board has also created a special webpage dedicated to sharing timely updates on various Board initiatives with a health care provider focus. Visit What Providers Need to Know to view the latest! 

For CMS-1500 feedback and questions, email CMS1500@wcb.ny.gov. For clinical feedback and questions, email provider@wcb.ny.gov.