Update Regarding Medical Narrative Attachments
As you know, the Workers’ Compensation Board (Board) strongly encourages health care providers to include the following three elements on most medical narrative attachments to the CMS-1500, and reiterates that certain narratives lacking one or more of these may be found legally defective:
- Causal relationship
- Work status
- Temporary impairment
There are several instances, however, in which this information is not as critical to the payer, or the Board, and it is not needed to properly adjudicate the medical bill. One example is a claim in which the injured worker has reached maximum medical improvement (MMI) and a permanent partial disability (PPD) classification has been made.
Moreover, certain provider types are not permitted to give formal opinions on causal relationship or degree of impairment. For full details, please see the WCB authorized providers: Who can do what chart on the Board’s website.
In a communication dated November 18, 2022, payers were notified that they should not routinely file a Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B) to deny payment to health care providers solely based on the absence of one or more of these three elements.
Such legal objections may be resolved in favor of health care providers if this is the sole basis for the dispute, and the information is deemed by the Board to be present, clearly implied, or not critical to the administration of the claim at the time of the clinic visit.
If a payer objects to a bill, the legal objection that was filed must be resolved first. If the bill is still not paid after it has been resolved in their favor, providers can file a Request for Decision on Unpaid Medical Bills (Form HP-1.0).
More information
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 health care provider focus. Visit What Providers Need to Know to view the latest.
For CMS-1500 feedback and questions, email CMS1500@wcb.ny.gov.
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