CMS-1500 Form Update - CARCs/RARCs

As you are likely aware, the Workers’ Compensation Board (Board) implemented the mandatory use of the CMS-1500 form plus medical narrative for all medical bills issued on or after July 1, 2022. 

Additionally, one of the requirements for payers is that they must provide the Explanation of Benefits (EOBs) electronically to health care providers identifying the same Claim Adjustment Reason Codes (CARCs) as specified on Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B) or Notice to Health Care Provider and Claimant of an Insurer's Refusal to Pay All (or a portion) of a Medical Bill Due to Valuation Objection(s) (Form C-8.4) when the associated medical bill was received electronically. Payers are required to provide EOBs with CARCs when they begin to use the new versions of Form C-8.1B or Form C-8.4, which becomes mandatory by September 19, 2022.

Please be advised of the following CARC and Remittance Advice Remark Code (RARC) updates:

• Apportionment: Payers should use the new CARC P32 – Payment Adjusted Due to Apportionment when reducing the payment to a provider as a result of apportionment of the liability among other injuries.
• Request for Taxpayer Identification Number and Certification (W-9) not on file:
  • Payers may use CARC 252 - an attachment or other documentation is required to adjudicate this claim/service, along with
  • RARC N836 - Provider W-9 or Payee Registration Not on File to report that payment is withheld pending receipt of the provider’s federal tax identification number on a form W-9. This should be used on the EOB only, and payers should not file Form C-8.1B since it is not a true legal objection.

Note: Although the Board does not consider lack of a W-9 to be a valid legal objection, it is understood that lack of the W-9 could delay payment. These payment issues should be resolved directly between the health care provider and the payer.

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.