Workers’ Compensation Provider Billing FAQs

A workers’ compensation provider is a doctor, hospital, or other healthcare provider that provides services to injured workers who are covered by the Workers’ Compensation Law.

You may come across several billing terminology and this section will help answer some of your questions. This section is based on New York state workers compensation guidelines.

If you’re billing for any services that are not related to workers’ compensation, those charges should be billed separately from the workers’ compensation claims that you submit to your insurance company. For example, if you’re filing a claim for an injured worker but also treating them for another condition like diabetes, then those billings should be separated so that only the portion related to their injury is paid for through workers’ compensation insurance benefits and not their health insurance plan as well.

Do all CMS-1500 submissions require a medical narrative or form attachments?

Yes, all CMS-1500 forms require a medical narrative or attachments when submitted through a clearinghouse, XML submission partner, or directly to the Workers’ Compensation Board. The Board provides a medical narrative report template for each provider’s CMS-1500 submission. Therefore, XML submission partners must reject CMS-1500 submissions without medical narratives or attachments.

Does data of the CMS-1500 require the same format for submissions to the payer and the Workers’ Compensation Board?

No. The Workers’ Compensation Board has specific requirements for electronic CMS-1500 transfer submissions. As a result, the electronic transfer for payer’s requirements may differ and require verification.

Does the CMS-1500 replace the C-4.3 form?

No, CMS-1500 does not replace the C-4.3 form.

Does the Workers’ Compensation Board accept a paper CMS-1500 form?

Yes, the Workers’ Compensation Board will accept a paper CMS-1500 but strongly encourages electronic submission via the XML submission process.

How are EOBs/EORs transmitted from the payer to the medical provider?

A payer must electronically submit EOBs/EORs to the XML submission partner with the submission of the electronic CMS-1500 form. However, a payer may send the EOBs/EORs to the medical provider via a mutually agreed method if the CMS-1500 was not submitted electronically. Specific CARC codes must identify objection reasons for payer EOBs/EORs or X12 835 transactions.

What methods are available to submit the CMS-1500?

Providers should utilize electronic submission via an XML submission process to submit the CMS-1500.

What is the process to submit only to the Workers’ Compensation Board if there is no payer or an undetermined payer?

The medical provider should obtain the patient’s employer’s name and address. However, if the patient is unsure of the correct employer, they must contact their human resources office or supervisor. In addition, New York state employers must conspicuously post the Notice of Compliance – Workers’ Compensation Law (Form C-105) within the workplace to identify the correct employer Workers’ Compensation insurance carrier name, address, phone number, and policy number.

Will insurance carriers accept copies of the original red CMS-1500 form?

Insurance carriers should accept copies of the original CMS-1500 form. However, submission does not require the original red CMS-1500. The document must provide clarity for payers and the scanning of the Workers’ Compensation Board.

Does the “Currently Authorized” column of the “Listing of Providers Authorized to Submit XML Data” report indicate authorization of the provider to submit XML or imply WCB authorization?

The “Currently Authorized” column indicates WCB authorization and authorization to submit XML data.

What is the correct method to identify a patient’s birth sex if Field 3 (birthdate, gender) on the CMS-1500 only allows for male and female, but the patient identifies as neither?

Field 3 is optional and completed if correct data is known. However, if the patient identifies as neither male nor female, leave Field 3 blank.

Is a new XML Submission Agreement required to submit the CMS-1500 if completed to submit the EC-4NARR?

No. Providers must only submit the XML Submission Agreement to the Workers’ Compensation Board once.

Must providers first register with the Workers’ Compensation Board to begin submitting the CMS-1500, medical narrative, and attachments?

Providers must complete the online Medical Portal registration process and agree to the legal agreement terms by selecting the “Agreement for XML submission of CMS-1500” within the Billing section before the Board will accept electronic CMS-1500 submissions.

How can I submit the CMS-1500 form using the XML submission process if my clearinghouse is not registered as a Workers’ Compensation Board XML submission partner?

Clearinghouses interested in becoming XML partners must register with the Workers’ Compensation Board. Then, submission partners must test the CMS-1500 XML submission process and become approved for implementation. The clearinghouse may work with an approved XML submission partner if they do not want to become a direct submission partner.

Where can I receive additional billing information?

The medical provider should obtain the patient’s employer’s name and address. However, if the patient is unsure of the correct employer, they must contact their human resources office or supervisor.

In addition, New York state employers must conspicuously post the Notice of Compliance – Workers’ Compensation Law (Form C-105) within the workplace to identify the correct employer Workers’ Compensation insurance carrier name, address, phone number, and policy number. In addition, providers may obtain information using the Employer Coverage Search app located on the Workers’ Compensation Board’s website.

What are the unique CMS-1500 requirements for chiropractors?

Chiropractors do not have unique CMS-1500 requirements. However, chiropractors must utilize the initial and subsequent narrative report requirements of the CMS-1500.

How can I become a Workers’ Compensation Board authorized provider?

Providers must apply to become a Workers’ Compensation Board authorized provider.

How can I verify that a clearinghouse is in the process of becoming a CMS-1500 XML submission partner?

The Workers’ Compensation Board publishes a listing of clearinghouses interested, testing, and approved to become a CMS-1500 XML submission partner.

Does the Expanded Provider Law affect how I submit the CMS-1500 via XML?

The Expanded Provider Law requires licensed clinical social workers, nurse practitioners, acupuncturists, physician assistants, occupational therapists, and physical therapists to bill as rendering providers. Providers must complete the online Medical Portal registration process and agree to the legal agreement terms by selecting the “Agreement for XML submission of CMS-1500” within the Billing section before the Board will accept electronic CMS-1500 submissions.

Explain the requirements of the TIFF-formatted medical narrative and image of a completed CMS-1500.

All images must have sufficient clarity, and the provider must ensure adequate quality. Specific requirements to ensure passing the upload process include:

  • TIFF-4-format, such as TIFF using ‘CCITT Group 4 Fax compression
  • The filling order must include the “Most Significant Bit (MSB) to Least Significant Bit (LSB)”
  • Only single-strip images
  • No tiled images
  • 200 dpi
  • Only black and white with a color depth of 1 bit
  • One image per file, no multi-page TIFF files, convert a duplex document into two image files

How should I submit a CMS-1500 for surgery when another physician, nurse practitioner, or physician assistant assisted the surgeon?

Enter the surgeon’s Rating Code within Field 19, the license number and NPI in Field 24J, and sign the bill in Field 31. Utilize Modifier 83 in Field 24D to identify assistant services by a physician assistant or nurse practitioner. Use Modifier 80 to identify surgery assistant services by another physician. In addition, include the name, license number, and NPI of a surgical assistant provider within the medical narrative.

Which methods are acceptable for sending the CMS-1500 to the XML submission partner?

Providers may submit the CMS-1500 to the XML submission partner on any mutually agreeable method, such as EDI, mail, fax, email, portal, etc.

What is the process when I receive acknowledgment of a paid bill but have not received payment?

The provider may submit a Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0) using the OnBoard online system for unpaid bills after 45 days of the payer acknowledging the medical bill. Do not resubmit because the clock will restart, and the provider must wait an additional 45 days to respond or pay.

What are the specific requirements for durable medical equipment (DME) supplies when submitting a CMS-1500?

Durable medical equipment (DME) suppliers must include their eight-digit Medicaid Management Information System (MMIS) number into Field 24J of the CMS-1500 or the medical narrative attachment when submitting a CMS-1500 to an XML submission partner.

Who is required to register for XML submission if we are a small medical practice using a third-party administrator to submit Workers’ Compensation bills?

The treating provider must register for XML submission, not the third-party administrator.

Are all providers required to become authorized by the Workers’ Compensation Board to submit the CMS-1500?

No. Particular urgent care, emergency department, out-of-state, and durable medical equipment (DME) providers are not eligible for authorized Workers’ Compensation Board treatment. Providers must register for XML submission to submit bills electronically via an XML submission partner.

Where should the second ordering provider’s information apply on the CMS-1500 if there are two different ordering providers since only one provider can submit data in Field 17?

One provider will enter their information, such as name, state license number, and NPI, in Fields 17, 17a, and 17b. The second provider must enter their information in the attached medical narrative.

When will I know the payer accepted my bill?

You will receive verifiable acknowledgment data on record when submitting electronically to show the payer received the bill. Then, the payer must remit the payment within 45 days.

What are the required timeframes for submitting medical reports?

The timeframes for submitting medical reports to the Workers’ Compensation Board and the payer, according to NYCRR 325-1.3, are:

  • Submit the initial CMS-1500 (formally the C-4, OT/PT-4, PS-4) within 48 hours of the initial treatment.
  • Submit subsequent CMS-1500 (formally the C-4.2, OT/PT-4, PS-4) within 15 days after the initial treatment and for continuing treatment. Each follow-up visit is not more than 90 days apart unless medically necessary.

Do all payers accept CMS-1500?

All payers must accept paper, electronic, EDI, or other mutually agreed formats CMS-1500.

Can providers view patient medical records through clearinghouses?

Clearinghouses utilize their services to medical providers. Therefore, you should confirm the services offered by clearinghouses.

Do clearinghouses use medical records from Medicare, Medicaid, or private insurers to dispute WCB claims?

The CMS-1500 initiative does not endorse data sharing outside the Workers’ Compensation system. In addition, providers must not simultaneously bill Workers’ Compensation payers and insurers for the same service. However, Workers’ Compensation Law 13(a) requires employers to promptly provide services to an injured employee, including medical, dental, surgical, optometric, or other treatment modalities.

Where should I enter the provider’s WCB authorization number and rating coding on the CMS-1500?

Enter the provider’s authorization number and rating code in Field 19 on the CMS-1500.

Are medical narrative attachments required for patients with a lifetime approved benefit?

Medical narrative attachments are required for all medical bills, regardless of the patient’s permanent classification.

Does the Workers’ Compensation Board website provide an area to upload medical narratives manually?

Yes, the Workers’ Compensation Board website allows one to upload medical reports.

Is the provider required to use the same clearinghouse (XML submission partner) as the payer during electronic submissions?

No, the provider is not required to use the same clearinghouse as the payer. For example, clearinghouses utilize multiple agreements with other clearinghouses to ensure prompt submission to payers when passing bills electronically.

Can I bill the patient if the bill becomes rejected?

No, you can not bill the patient if the payer rejects the bill according to Section 13-f of the Workers’ Compensation Law.

When can the provider submit an initial medical bill or report for treatment to the payer and the Workers’ Compensation Board?

The initial medical treatment may become submitted to the Workers’ Compensation Board and the payer based on medical decisions. As a result, the medical provider should submit the bill or report to the XML submission partner if the patient has a reportable Workers’ Compensation injury beyond first aid. The WCL does not necessitate an employer who wishes to pay for medical treatment directly.

Are system and workflow changes required to send to the Workers’ Compensation Board proprietary data elements for the provider WCB Rating Code and Authorization Number due to lack of support in the X12 837?

No, changes are not necessary to your existing workflow process. As a result, the XML submission partner will process the electronic indexing to the Workers’ Compensation Board’s field table matrix to ensure the WCB Rating Code and Authorization Number of the CMS-1500 form and compliant XML documentation.

Are there any attachment format changes to comply with the NYS Workers’ Compensation Board attachment requirements when submitting attachments to our clearinghouse for Property and Casualty Commercial payers?

No. Approved XML submission partners will ensure the attachment format conversion process complies with the Workers’ Compensation Board’s format requirements.

When is the CMS-1500 used?

The CMS-1500 is a standard claim form for medical providers to bill the Centers for Medicare and Medicaid Services (CMS) and health insurers.

Can a casual relationship cause a rejected CMS-1500? What are the criteria used by the Workers’ Compensation Board for judgment of work-related causation?

The CMS-1500 requires a medical narrative report attachment. Three mandatory elements of most medical narratives include:

  • The patient’s work status
  • The causal relationship
  • The temporary impairment percentage

The CMS-1500 may become rejected if the narrative medical report of the three elements is missing. However, the CMS-1500 does not change information related to a payer’s assessment of a casual relationship.

Can I use the CMS-1500 form to bill for medical testimony?

Use the CPT code 99075 on the CMS-1500 to utilize medical testimony. Medical services billing regulations do not adhere to medical testimony bills and are not subject to the standard 45-day payment period. As a result, a CARC code does not exist, and payers do not file a legal or valuation objection for payment.

Are electronically submitted CMS-1500 forms required to submit to the Workers’ Compensation Board?

No, providers who submit the CMS-1500 electronically via an XML submission partner will advance to the carrier and the Workers’ Compensation Board.

What occurs if a provider leaves out information from the CMS-1500 narrative?

Missing mandatory elements of the CMS-1500 narrative, such as the patient’s work status, a causal relationship to the injury and work activities, and temporary impairment percentage may become legally defective.

Can an occupational or physical therapist submit a temporary impairment percentage on the CMS-1500?

Occupational and physical therapists do not enter information regarding a causal relationship or temporary impairment percentage.

Does the Workers’ Compensation Board still accept faxed claims?

No, the Board no longer accepts faxed claims. However, the Workers’ Compensation Board accepts claims through electronic submissions, XML submission partners, mail, email, or web upload.

Is there a list of payers that do not accept electronic claims?

All Workers’ Compensation payers must electronically accept the CMS-1500, EDI, or other mutually agreed forms, effective October 1, 2021.

Are specified narrative requirements to daily progress notes necessary when applying for CMS-1500 submission?

Yes, the CMS-1500 Requirements page of the Workers’ Compensation Board outlines detailed information required on the medical narrative attachment.

How can I electronically submit the attached medical narrative?

Coordinate the process and format the electronic submission with your XML submission partner. An approved XML submission partner can submit the attachment format in compliance with Workers’ Compensation Board requirements.

Can I utilize a SOAP note generated by treatment visits that do not include all of the information during a re-exam for the medical narrative requirement of the CMS-1500?

  • The medical narrative for the CMS-1500 has three mandatory elements:
  • The patient’s work status
  • The causal relationship
    The temporary impairment percentage
    A medical narrative may become legally defective if missing the mandatory elements.

Can providers hire an XML submission partner, or does the insurance company hire their XML submission partner to submit medical claims?

Providers should partner with an approved XML submission partner to ensure the medical bill, and narrative attachment are sent and accepted by the appropriate payer.

Is there a penalty for not billing through an XML submission partner?

No, utilizing an XML submission partner is encouraged but not required.

Are DME suppliers required to bill using a CMS-1500 form and provide a medical narrative, even if they do not examine the patient?

Yes, DME suppliers are required to bill using the CMS-1500. In addition, the accompanying attachment must include a copy of the physician’s prescription (order) for the DME items and proof of enrollment certification in the NYS Medicaid program, including the Medicaid Management Information System (MMIS) number.

If my office decides to submit a paper CMS-1500, must we register for the Medical Portal?

Yes, providers are strongly encouraged to register for the Medical Portal to apply to become Workers’ Compensation Board authorized, renew an authorization, update practice information, receive training on the user’s roles, access lookup tools for the Workers’ Compensation Board’s Medical Treatment Guidelines and Drug Formulary, execute the User Agreement to submit CMS-1500 medical bills through an XML submission process.

In addition, providers can use the Medical Portal to access OnBoard: Limited Release, delegate users when submitting prior authorization requests, and Request for Decision on Unpaid Medical Bills (Form HP-1.0).

May a provider submit a completed Form C-4 or Form C-4.2 for a CMS-1500 attachment to demonstrate medical necessity and compliance with the MTGs?

The Workers’ Compensation Board discontinued Form C-4 and Form C-4.2 as of July 1, 2022. Instead, the Workers’ Compensation Board created a medical narrative report template to complete each CMS-1500 submission.

Will each medical provider have their own electronic payer ID if we submit bills electronically?

Insurers and employers may self-insure for Workers’ Compensation benefits with New York state by utilizing an assigned seven-character identification number on the Payers’ XML Submission Partner Lookup webpage. Approved XML submission partners and clearinghouses are competent about the correct Payer ID required to deliver electronic medical bills to the payer.

Will each medical provider affiliated with a group practice need to individually register for the Medical Portal and XML submission of the CMS-1500?

Yes, each provider who wants to submit the CMS-1500 using the XML submission process must first complete the online Medical Portal registration process. Providers who have not yet signed up for XML submission of the CMS-1500 will see a link under the Billing section “Agreement for XML submission of CMS-1500” when logging into the Medical Portal.

If the CMS-1500 does not replace the C-4.3, can I submit the C-4.3 electronically using an XML submission partner?

Using an XML submission partner, you may use the CMS-1500 to submit medical bills for permanency evaluations electronically. Medical providers should:

  • Only use CPT codes 99243 or 99245
  • Only use one CPT code, 99243 or 99245, on the medical bill
  • Attach a completed C-4.3 to the CMS-1500 as the medical narrative
  • Do not send a C-4.3 to the Board separately

How can I use the CMS-1500 paper version when more than six procedures, services, or supplies on one date of service?

You may submit multiple CMS-1500 forms if there are more than six line items for one service date when the total charge amount appears only on the last form.

How can I electronically submit bills for apportioned claims?

You should clearly state the apportioned bill on the medical narrative attachment and include other WCB case number(s) and carrier claim numbers when submitting an apportioned bill.

Please refer to your state’s Workers’ Compensation Board website or speak with a Workers’ Compensation attorney for additional information.

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