Key Takeaways

• The New York Workers’ Compensation Board will consolidate and eliminate certain medical billing forms and convert to the CMS-1500 form—currently used for CMS billing to allow for more universal submission of billing electronically

• Beginning October 1, 2021, Phase 2 will make acceptance of CMS-1500 Forms mandatory

• Beginning July 1, 2022, Phase 3 will put new standards and requirements in place for providers and insurers/payees

• The timeframe to submit bills has been extended from 90 to 120 days in most circumstances

To reduce the administrative burden and increase provider participation, the New York Workers’ Compensation Board will consolidate and eliminate certain medical billing forms and convert to the CMS-1500 form—currently used for CMS billing to allow for more universal submission of billing electronically.

As part of the CMS-1500 initiative, the Board has updated Form C-8.1 and Form C-8.4. The update is meant to clarify potential legal and valuation objections, respectively, and to eliminate certain obsolete sections currently found on the left side of Form C-8.1, including Part A: “Notice of Objection Regarding Further or Future Treatment.”

With the elimination of Part A, the question “requested treatment is not for an established site or condition” will be moved to Form RFA-2. A new version of Form RFA-2 will be published later in 2021. Additionally, Form C-8.1 will be renamed Form C-8.1B and become effective on July 1, 2021. After August 15, 2021, the current versions of the forms will not be accepted, and no action will be taken by the Board should an insurer continue to use them. Only the new forms, dated July 2021, will be accepted.

A new objection reason has been added to Form C-8.1B to allow insurers to object to a medical bill if it is not sent in an electronic format (CARC P13, RARC M117). This objection reason will be valid once the provider’s grace period for electronic submission of Form CMS-1500 expires on August 15, 2021, unless the provider has been granted a waiver by the Board. Thus, insurers may commence using this objection reason for any bills submitted by providers on or after August 16, 2021.

Insurers must remit payment or object to payment of the bill within 45 days from when the bill is received by the insurer. The acknowledgement date on the Form CMS-1500 (field 19) is the start date for the 45-day period. If the bill is not electronically submitted, the 45-day period will start on the date the bill was received by the Board.

Insurers have the option of sharing Forms C-8.1B and C-8.4 with providers by offering secure online access to their systems. For requirements, please see Subject Number 046-1362.

A layout of the new procedures:

• Beginning October 1, 2021, providers must electronically accept Form CMS-1500 and electronically return acknowledgements of receipt of these bills to the XML submission partner (clearinghouse).
• Insurers and payees will be required to send explanation of benefits/explanations of review (EOBs/EORs) back to providers through the clearinghouse by July 1, 2022. The clearinghouse will submit the bills, EOB/EORs, and disputes to the Board.
• The use of EOB/EOR forms will require payers to use specific Claims Adjustment Reason Codes (CARC) when objecting to payment.
• The insurer must send the Board and other required stakeholders a timely filed Form C-8.1B or Form C-8.4 with the same objection reason(s) noted to properly object to such payment. All objections must be made at the same time. The new forms have been updated to include the associated CARC and RARC codes.
• Providers, based on receipt of the EOB/EOR with required CARC codes, may file Form HP-1 to transmit any disputes for unpaid medical bills.

The need for C-8.1B or C-8.4 forms may, down the road, be eliminated if EOB/EOR data with required CARC codes was transmitted to the provider through a clearinghouse.

The timeframe for submission of medical bills has also changed slightly. Approved medical care providers shall submit bills to the employer, insurance carrier, or third-party administrator either within 120 days from the last day of the month in which services were rendered, or 90 days from the last day of the month in which the claimant received the final treatment in a continuous course of treatment. Hospitals shall submit bills for out-patient hospital services to the employer, insurance carrier, or third-party administrator within 120 days from the last day of the month in which the treatment was provided. Bills submitted in any other format or outside this time requirement shall not be eligible for an award by the chair under the provisions of the workers’ compensation law.

These are also significant changes to the medical bill process for both providers and insurers/payers. As Phase 2 is set to begin soon, it is imperative that our clients have a firm grasp and understanding of the updated forms and new processes. More information about Phase 2 and the proposed timeline for the CMS-1500 Initiative is available online.

If you have any questions about these changes or how they impact your business, contact:

• Amanda R. Amendola
• Christina M. Hassler
• Damon M. Gruber
• Sean J. McKinley
• Esther F. Omoloyin
• Or another member of our Workers’ Compensation practice