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New York updates payer compliance requirements for CMS-1500 project

October 6, 2021 · Public Policy & Regulatory Affairs Team

With pending implementation of several CMS-1500 projects, on September 29, 2021, the New York Workers’ Compensation Board (WCB) updated compliance requirements for payers impacted by the project. CMS-1500 directs payers and providers to share billing information and related transactions electronically using the prescribed form and formats. 

The most recent release reminds stakeholders that effective October 1, 2021 payers must:

  • Electronically accept Form CMS-1500 via EDI or other agreed-upon format. Payers will electronically transmit the EOB/EOR to their XML submission partners upon the adjudication of the submitted electronic CMS-1500 medical bill.

  • Acknowledge medical bills within seven business days. Payers must accept an electronic bill from an XML submission partner when it is transmitted using EDI or another format agreed upon with the XML submission partner.

While the first two pieces of the transactional business processes took effect October 1, 2021, two additional pieces of the project take effect a bit later, when payers must:

  • Designate their XML submission partner by October 31, 2021. Payers must designate at least one XML partner and must keep XML submission partner information accurate and update the WCB online system within three business day of any changes.

  • Identify all legal and valuation objections for payment of the medical bill and submit them at the same time and on the same EOB/EOR by November 1, 2021. Payers are required to make such objections within 45 calendar days of acknowledgment of receipt of the medical bill whether on paper or digital.

  • As of November 1, 2021, payers must continue to file the current versions of the C‑8.1B and C‑8.4 forms with the WCB along with a copy of the EOB/EOR to object to a payment of a bill.  

Impacted services

The application of the CMS-1500 project applies to all medical services, which includes ancillary care such as physical and occupational therapy and home healthcare but does not apply to bills submitted for pharmacy or durable medical equipment. 

Additionally, at this time, providers are not required to submit electronic medical bills, the date for this requirement is currently projected for July 1, 2022. 

While this update provides key elements of the current status of the CMS-1500 project, it does not cover the entirety of the project requirements.  More information on the project can be found, here.

Our Public Policy and Regulatory Affairs team will continue to monitor regulatory developments tied to the CMS-1500 project and will communicate any important project changes or updates.  

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