CMS-1500 Form: Important Reminders for Payers

New York State Workers' Compensation Board sent this bulletin at 04/18/2022 09:00 AM EDT

CMS-1500 Form: Important Reminders for Payers

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 Date Requirements

Beginning July 1, 2022, you will need to:

  • Use the new (7/22) versions of the Notice of Treatment Issue/Disputed Bill (Form C-8.1B) and 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), with applicable Claim Adjustment Reason Codes (CARCs), to object to medical bills. However, the Board will continue to accept the older versions of Form C-8.1B and Form C-8.4 until September 19, 2022.
  • Provide the Explanation of Benefits (EOBs) electronically to health care providers identifying the same CARCs as specified on Form C-8.1B or Form C-8.4 when the associated medical bill was received electronically.

Please Note: Noncompliance with this directive may result in monetary penalties, including referral to the New York State Department of Financial Services.

  • Continue to keep XML submission partner designation(s) accurate and up to date.

A listing of approved XML submission partners for the CMS-1500 initiative is posted on the XML Forms Submission section of the Board's website and is updated after each entity successfully completes testing and executes an XML submission partner agreement with the Board.

Payers' Medical Portal online administrators can use the online administrator application to designate XML submission partner(s). Information for payers' XML submission partner designation is on the Board’s website.

For more information, see Subject Number 046-1452.

Simultaneous Objections

As a reminder, as of November 1, 2021, 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. 
  • Make such objections within 45 calendar days of acknowledgement of receipt of the medical bill (whether on paper or digital).
  • Continue to file such objections with the Board using the current versions of the Form C-8.1B and/or 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). The Form C-8.1B and/or C-8.4 should also be sent to the health care provider.

Additional Resources

You can visit the Board’s website for a CMS-1500 overview, news, FAQs, and more. 

For CMS-1500 feedback and questions, or to request a copy of Forms C-8.1B and C-8.4, email CMS1500@wcb.ny.gov.