CMS-1500 Form – Important Reminders for Health Care Providers
As you are likely already aware, the Workers’ Compensation Board (Board) is in the process of transitioning to the CMS-1500 form, which will streamline the medical billing process and reduce the paperwork requirements currently in the workers’ compensation system. We expect that a more straightforward billing process will draw more health care providers into the system, leading to better access to health care providers and more timely care for injured workers.
The July 1, 2022, implementation date is quickly approaching, and we want to make sure you are prepared. Read on for some important reminders to be aware of.
Effective July 1, 2022:
Health care providers are required to:
- Use the CMS-1500 form for all workers’ compensation medical billing. Electronic submission through an XML submission partner is strongly encouraged, though not currently required.
- Include the injured worker’s (1) temporary impairment percentage (2) work status, and (3) the causal relationship of the injury at the top of the medical narrative that accompanies the CMS-1500 form. Important: If any of these elements are missing, the medical narrative report may be found legally defective, which means injured workers may not get needed benefits and you may not be paid. Bills for ancillary services such as radiology, anesthesiology or surgery have unique attachment requirements.
Register for XML Submission
You 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 submission of medical bills to payers and the Board.
Once you are registered for electronic submission, you can then discuss details of submission with 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.
Benefits of XML Submission
We encourage you to start using the CMS-1500 form now. Electronic submission offers numerous benefits:
- Confirmation within seven days that a bill was accepted or rejected by the payer.
- Typically, quicker payment.
- With acknowledgement of receipt from the payer, awareness that a bill should not be resubmitted.
- Technical errors are identified quickly so they may be corrected and resubmitted, instead of waiting for the payer to deny the bill.
Between now and July 1, 2022, you are urged to review your processes to understand how these changes will affect you. The Board will continue to post periodic updates to the website based on feedback and questions received from stakeholders.
Discontinued Forms
When mandatory submission of the CMS-1500 form begins on July 1, 2022, use of the following forms will be discontinued:
- Doctor’s Initial Report (Form C-4, Form EC-4)
- Continuation to Carrier/Employer Billing Section (Form C-4.1)
- Doctor’s Progress Report (Form C-4.2, Form EC-4.2)
- Ancillary Medical Report (Form C-4AMR, Form EC-4AMR)
- Doctor’s Narrative Report (Form EC-4NARR)
- Occupational/Physical Therapist’s Report (Form OT/PT-4, Form EOT/PT-4)
- Psychologists Report (Form PS-4)
- Ophthalmologist's Report (Form C-5)
Pursuant to 12 NYCRR 325-1.25(b)(1), effective July 1, 2022, bills submitted on any of the above forms shall not be eligible for an award issued through the medical dispute process under the provisions of the Workers' Compensation Law.
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.
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