Payer Reminder Regarding Objections to Medical Bills

As you know, mandatory use of the CMS-1500 form went into effect on July 1, 2022. In a GovDelivery dated June 27, 2022, the Workers’ Compensation Board (Board) shared several reminders for payers, including requirements for objections to medical bills.

Per Subject Number 046-1362R3, starting September 19, 2022, payers must do the following:

• Use the updated (July 2022) Notice of Treatment Issues/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) to notify the Board of legal and valuation objections, respectively.
• Use standardized objection reasons, also known as Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs), on an Explanation of Benefits/Explanation of Review (EOB/EOR) sent to a health care provider to object to payment of a medical bill. The payer must send the Board (and other required stakeholders) a timely filed Form C-8.1B or Form C-8.4 with the same objection reason(s) noted to properly object to such payment. All objections must be made at the same time. The new forms have been updated to include the associated CARC and RARC codes.

As a reminder, payers must remit payment or object to payment of a medical bill within 45 calendar days from when the bill is received. The acknowledgement date transmitted by the payer to the XML submission partner and displayed on the CMS-1500 form (Field 19) is the start date for the 45-day period. If the bill is not submitted electronically, the 45-day period will start on the date the bill was received by the Board.

Additional Resources

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.