Change to Form C-8.4 and Confirmation of Scenarios where an Objection Should Not be Sent
Please be advised the Workers’ Compensation Board (Board) has made a change to the 7/1/22 version of the 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) to remove the preferred provider organization (PPO) objection.
Payments may be appropriately reduced, but objections should not be submitted by the insurer to the Board in the following scenarios:
- The amount billed for the particular CPT code is in excess of the amount designated by the applicable medical fee schedule, and the insurer pays the bill at the appropriate medical fee schedule amount.
- The insurer reduces the amount of the bill to 12, 15 or 18 relative value units for evaluation services and modalities, as set forth in the applicable medical fee schedule.
- The insurer reduces the amount of the bill pursuant to a contractual agreement with the provider (e.g., network or PPO discount).
- There is a duplicate bill.
Additionally, since Form C-8.4 should be filed simultaneously by the insurer with Notice of Treatment Issue/Disputed Bill (Form C-8.1B), the Board is extending the grace period to 81 days (September 19, 2022) for both forms. Old versions of both forms will not be accepted after September 19, 2022.
More information
You can visit the Board’s website for a CMS-1500 overview, news, FAQs, and more.
For CMS-1500 feedback and questions email CMS1500@wcb.ny.gov.
To request a copy of Forms C-8.1B and C-8.4, email FormsDepartment@wcb.ny.gov.
|
