Payer Requirements Starting Today

Starting today, September 19, 2022, per Subject Number 046-1362R3, 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.

When completing Form C-8.1B and the objection reason requires a CARC with an associated RARC, payers should review the X12 code sets and select the most appropriate, valid CARC/RARC code combination.  Payers should not enter erroneous codes on the form.  Additional X12 CARC/RARC codes may be found on the X12 website.

To ensure timely adjudication of Form C-8.1B or Form C-8.4, payers should complete all stakeholder claim information found in Section A, Fields 1 through 11, including the provider’s National Provider Identifier (NPI).

Effective August 17, 2022, the Board updated the CARC and RARC codes required when objecting to payment of medical bills, which now include four scenarios where an objection Form C-8.1B or Form C-8.4 is not required but the CARC/RARC codes should be included on the EOB.  These include:

• Amount of bill exceeds the relative value units for evaluation and services modalities as set forth in the applicable medical fee schedule;
• Amount of bill reduced pursuant to contractual agreement;
• The provider’s federal taxpayer identification number is not on file; and
• Payment adjusted due to a resolved apportionment.

If any of the above scenarios are the ONLY reason for non-payment of a medical bill, an objection Form C-8.1B or Form C-8.4 is not required.  Payers will have up to 90 days (November 15, 2022) to implement these four new CARC/RARC code scenarios.

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.

Mandatory use of the CMS-1500 form went into effect on July 1, 2022. Additional details outlining all payer requirements can be reviewed in a GovDelivery dated June 27, 2022.

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.