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As you are aware, on August 1, 2024, the Board issued Subject Number 046-1707 which required the mandatory electronic submission of the CMS-1500 by providers beginning August 1, 2025.
Contained within that Subject Number was the following guidance, which is applicable to providers and payers alike:
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 Worker's 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.
Therefore, the significant advantage of requiring mandatory electronic submission of CMS-1500 forms was explicitly contingent upon providers' ability to offset the cost of electronic delivery through a minimal CPT Code 99080 fee.
REQUIRED: PAYMENT OF CODE 99080
As we draw near to the full implementation of electronic submission of CMS-1500 on August 1, 2025, the Board wishes to remind the payer community that payment of CPT code 99080, in amounts billed at $1.00 or less, is not optional.
By way of illustration, the Board provides guidance in the CMS-1500 FAQ section of its website for these specific factual scenarios.
Payers are instructed to remit payment for the 99080 charge as specified above. Additionally, they are advised not to submit objections to CMS-1500 forms - whether through Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B) or 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) - when the only basis for the objection is the inclusion of CPT code 99080 with an amount of $1.00 or less.
Further, the Board wishes to remind payers that the provisions of WCL §13-a(6)(b) require that objections to medical treatment be reasonable and warranted. Accordingly, in the event that payers do not pay the charge associated with the CPT Code 99080 and/or file objections to CMS-1500 forms solely as a result of same, payers may be subject to penalties pursuant to WCL §§13-a(6)(b) and/or 114-a(3) where applicable.
MORE INFORMATION
Visit wcb.ny.gov/CMS-1500.
The What Payers Need to Know and What Providers Need to Know sections of the Board’s website walk payers and providers through getting started in the workers’ compensation system. Each section also features important updates for payers and providers.
If you have not already done so, be sure to sign up to receive Board news straight to your inbox, including updates on the progress of this initiative, upcoming webinars, and more.
QUESTIONS?
Email CMS1500@wcb.ny.gov.
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