HP-1.0 forms without proper documentation

Please be advised that effective March 1, 2024, any Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0) submitted to the Workers’ Compensation Board (Board) without proper documentation will be rejected.

As a reminder, payers are required to pay a health care provider's bill in full (assuming it is consistent with the applicable fee schedule) or submit a Notice of Objection to Payment of a Bill for Treatment Provided (Form C-8.1B) within 45 days of submission. If a payer has failed to do this, the health care provider may be able to request the Board's assistance by filing Form HP-1.0 through OnBoard.

Health care providers must provide supporting documentation with every submission of a Form HP-1.0, even if documentation was previously submitted to the Board when the bill was initially sent.

A complete medical bill must, by definition, include:

• a CMS-1500, AND
• the supporting medical narrative.

When submitting Form HP-1.0, providers must also attach:

1. Basis for provider belief that the clinical intervention was medically necessary; AND
2. Payer denial communications (if received); AND
3. Scenario-specific documentation.

Below breaks down the specific examples of documentation required:

1. Basis for provider belief that the clinical intervention was medically necessary

• If the clinical intervention at issue was consistent with the Workers' Compensation Board's New York Medical Treatment Guidelines (MTGs), please attach one of the following:
  • MTG Confirmation prior authorization request (PAR) granting the clinical intervention, OR
  • The summary page from the Board's MTG Look Up Tool, diagnosis, and clinical intervention in question. The MTG Lookup Tool can be accessed within the Medical Portal, OR
  • A copy of the applicable section of the appropriate MTG indicating that clinical intervention was "recommended" pursuant to the MTGs, OR
• Alternatively, if the clinical intervention at issue varied from the MTGs, or otherwise required a PAR, please attach one of the following:
  • A copy of the PAR granting the clinical intervention, OR
  • A copy of any Order of the Chair and/or Notice of Decision granting the clinical intervention, AND

2. Payer denial communication (if received)

If the provider has received from the payer a 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), that should be submitted as well. If received by the provider, this should also include an Explanation of Benefit communication from the payer, AND

3. Scenario-specific documentation

The Board has outlined specific documentation that should be provided in support of the most common billing dispute scenarios, which should also be submitted with the Form HP-1.0.

More information

The Board has updated the medical billing disputes section of the website to outline required documentation, the arbitration process, arbitration scenarios and recommended actions for both payers and health care providers, FAQs, and more.   

Email the Medical Director’s Office with any questions at DisputedMedicalBills@wcb.ny.gov or call (800) 781-2362.