CMS-1500 Form: Important Reminders for Payers

The July 1, 2022, CMS-1500 form implementation is quickly approaching.

As you are likely already aware, the Workers’ Compensation Board (Board) is transitioning to the CMS-1500 form, which will streamline the medical billing process and reduce the paperwork requirements currently in the workers’ compensation system. It’s expected 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.

We want to make sure you are fully prepared for implementation. Read on for some important reminders to be aware of.

Change to Form C-8.4

The Board has made a change to the July 1, 2022, 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. You can read more in the GovDelivery dated May 3, 2022.

Requirements Starting July 1, 2022

Beginning July 1, 2022, payers are required to:

• Use the new (July 1, 2022) 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.
• Continue to keep XML submission partner designation(s) accurate and up to date.

Please note: Noncompliance with these directives may result in monetary penalties, including referral to the New York State Department of Financial Services

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-8.1 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. The Board has also created a special webpage dedicated to sharing timely updates on various Board initiatives with a payer focus. Visit What Payers Need to Know to view the latest! 

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.