Important CMS-1500 update for health care providers

As was recently announced in Subject Number 046-1707, the Board will require health care providers to contract with an electronic submission partner to submit the CMS-1500 universal medical billing form electronically on their behalf beginning in 2025. This new requirement will allow for faster payments, greater accuracy and efficiency, and will improve injured workers’ access to timely, quality medical care.

The CMS-1500 electronic submission requirement for providers will become mandatory on August 1, 2025. As of that date, the Board will not take action on or enforce payment of a bill submitted on a paper CMS-1500 form. Forms that are submitted prior to August 1, 2025, will continue to be processed, but providers are encouraged to transition to electronic submission well in advance of the mandatory date, in order to reduce the likelihood of submissions being “lost” in the transition.

Submitting the CMS-1500 electronically has significant benefits, including:

• Faster bill payments.
• Reduced administrative burden – the electronic submission partner submits the CMS-1500 to the insurer and the Board.
• Increased certainty, including electronic acknowledgement of the insurer’s receipt (removing unnecessary duplicate submissions), and confirmation of acceptance/rejection of the bill within seven days.
• Faster identification and correction of technical errors, and quicker resubmission (no waiting until insurer denies the bill).
• No cost or low cost.

Please keep the following in mind:

• Providers will still have the ability to submit a paper CMS-1500 form to the electronic submission partner (who will then submit it electronically to the Board on the provider’s behalf).
• Payment may be denied when a bill is submitted improperly (i.e., not submitted electronically through an approved electronic submission partner).
• Providers decide which electronic submission partner they want to use. Costs and services may vary by company. View the Board’s list of approved electronic submission partners.
• Providers will have the ability to offset the cost of using an electronic submission partner by using code 99080, previously a “No Charge” (NC) code defined in the Official New York Workers’ Compensation Medical Fee Schedule as “Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form,” which may be used as a “By Report” (BR) code, up to a maximum value of one dollar. The code should be placed on the same CMS-1500 form for which the billable services payment and the electronic submission costs are being requested. The price listed by the provider for code 99080 should accurately reflect the actual cost incurred by the provider for the electronic submission of the individual bill, up to a maximum of one dollar.
• Providers are strongly encouraged to use the narrative template to create the medical narrative report that must be submitted with the CMS-1500 for ease of locating the essential elements of: causal relationship; work status; and impairment/disability level. For those using their own template, please remember to include these elements in a highly visible location on your reports.

Background

As part of the Board’s ongoing modernization, including the transition of many paper-based processes online, the Board transitioned to the CMS-1500 form in 2022 to reduce the administrative burden on health care providers and increase provider participation. CMS-1500 is the universal claim form used by medical providers to bill the Centers for Medicare and Medicaid Services as well as health insurers. The initiative leverages providers' current medical billing software and medical records while promoting a more efficient workers' compensation system.

More information

Visit the CMS-1500 section of the Board’s website for more information.

The What Providers Need to Know section of the Board’s website walks health care providers through getting started in the workers’ compensation system, treating injured workers, billing for services, and a Provider Updates page that features regularly updated news for the provider community.

If you have not already, be sure to sign up to receive Board news straight to your inbox or text messages, including updates on the progress of this initiative, upcoming webinars, and more.

Questions?

Email MDO@wcb.ny.gov.