New York Workers’ Compensation Board updates requirements and timeline of its CMS-1500 Billing Project

The New York Workers’ Compensation Board’s (WCB) latest update to their CMS-1500 project outlines recent changes in billing form/format requirements and an updated timeline for phasing out existing forms and using the CMS-1500 form.

CMS-1500 PROJECT REQUIREMENTS

The WCB is transitioning to the CMS-1500 form to streamline medical billing and reduce paperwork in the workers’ compensation system. The objective is to offer a more straightforward billing process and draw providers into the system, leading to better access to providers and timely care.

The WCB’s August update included the mandatory requirements that will be effective July 1, 2021 for all providers and payers.

Healthcare providers must:

• Submit the CMS-1500 form electronically – utilization of clearinghouses is permitted
• Submit the Request for Decision on Unpaid Medical Bill(s) (Form HP-1) electronically to advise date of service, provider and amount billed versus amount paid
• Attach the EOB with the payer Claim Adjustment Reason Codes (CARCs) to the Request for Decision on Unpaid Medical Bill(s) (Form HP-1)

Payers must:

• Electronically accept the CMS-1500 form.
• Use the new Notice of Treatment Issue/Disputed Bill (Form C-8.1) and Notice to Health Care Provider and Injured Worker of a Carrier's Refusal to Pay All (or a portion of) a Medical Bill Due to Valuation Objection(s) (Form C-8.4) with applicable Claim Adjustment Reason Codes (CARCs) to object to medical bills. CARCs will be on the revised forms.
• Provide EOBs electronically to providers identifying the same CARCs as specified on the Notice of Treatment Issue/Disputed Bill (Form C-8.1) or Notice to Health Care Provider and Injured Worker of a Carrier's Refusal to Pay All (or a portion of) a Medical Bill Due to Valuation Objection(s) (Form C-8.4).
• Identify all reasons for objection at initial determination of a medical bill.

OPTUM WORKERS’ COMP AND AUTO NO-FAULT EFFORTS

The Optum Public Policy and Regulatory Affairs team continues to engage and track all new information and developments related to the CMS-1500 Project and we will be communicating this information in future posts. Our Regulatory Implementation team is also directly engaging with each impacted line of business to ensure our full compliance with the new requirements and forms/formats.

It should be noted, at present, the CMS-1500 project only impacts the billing and handling of medical services and does not impact durable medical equipment and supplies (DMEPOS) and pharmacy transactions. However, it should be stressed that medical services such as physical and occupation therapy will be required to comply with the new billing requirements when effective. Between now and the implementation date, we urge our clients to review all the information available and engage internally or with Optum to ensure compliance.

Further information on the CMS-1500 Project and other forms/formats can be found here: http://www.wcb.ny.gov/CMS-1500/