Reminder: CMS-1500 submission requirement for health care providers

New York State Workers' Compensation Board sent this bulletin at 01/07/2025 01:00 PM EST

Reminder: CMS-1500 submission requirement for health care providers

Please be reminded that 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 August 1, 2025.

As was announced in a notification dated August 1, 2024, the Board will not act on or enforce payment of a paper CMS-1500 form submitted on or after August 1, 2025. 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 to reduce the likelihood of submissions being “lost” in the transition.

This new requirement will allow for faster payments, greater accuracy and efficiency, and will improve injured workers’ access to timely, quality medical care.

Submitting the CMS-1500 form 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:

  • Very important: When a WCB case number is available it MUST be populated in field 9A. Failure to do this may result in the CMS-1500 form not being matched with the correct case, resulting in delay of review and payment.
  • 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).
  • Enter the information correctly on the CMS-1500 form, including payer and employer detail, as indicated on the Requirements page of the Board’s website.
  • When the CMS-1500 form and narrative are submitted through an electronic submission partner, providers should not mail, fax, or email a duplicate bill to the Board.
  • 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.” Code 99080 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 amount entered under 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.
    Note: A provider who currently submits a CMS-1500 form electronically via an electronic submission partner can bill to offset the cost.
  • When billing for a permanency evaluation, the Doctor’s Report of MMI/Permanent Impairment (Form C-4.3) must be attached to the CMS-1500 as the medical narrative. If you send a separate C-4.3 form to the Board, it will be rejected.​
  • If there are more than six line items for one date of service, you must submit multiple CMS-1500 forms together with the total charge amount appearing only on the last form.
  • Providers who are required/permitted to do so are strongly encouraged to use the narrative template to create the medical narrative report that must be submitted with the CMS-1500 form for ease of locating the essential elements of:
    • causal relationship of the injury or illness to the patient’s work activities
    • patient’s work status
    • temporary impairment percentage

             For those using their own template, please remember to include these elements in a highly visible location on your reports.

Webinar training

For those not already using an electronic submission partner, the Board is pleased to offer provider webinars to ensure you are prepared for this.

The sessions are free and there will be time at the end for questions. Register here.

January 8, 2025
12:00 p.m. – 1:00 p.m.

January 15, 2025
12:00 p.m. – 1:00 p.m.

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 via text message, including updates on the progress of this initiative, upcoming webinars, and more.

Questions?

Email MDO@wcb.ny.gov.