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Things to know about the NY Workers’ Compensation CMS 1500 Form

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Things to know about the NY Workers’ Compensation CMS 1500 Form

Is New York Workers’ Compensation billing an important part of your medical practice’s revenues? Then you certainly need to know about the recent changes in the workers’ compensation claim procedure.

Two years ago, the Worker’s Compensation Board (WCB) simplified the claims process by replacing almost all the different forms (Table 1) with just one – the CMS 1500 form. You may be familiar with this form, as it is used by insurance companies and the Centers for Medicare and Medicaid Services (CMS).

Now, the NY WCB is adopting paperless XML submission. This is already in place, but may become mandatory next year. Are you ready?
Read ahead to find out everything you need to know about this change.

 

Table 1

———
Forms Replaced by the CMS-1500 Form
Doctor’s Initial Report (Forms C-4, EC-4)
Continuation to Carrier/Employer Billing Section (Form C-4.1)
Doctor’s Progress Report (Forms C-4.2, EC-4.2)
Ancillary Medical Report (Forms C-4AMR, EC-4AMR)
Doctor’s Narrative Report (Form EC-4NARR)
Occupational/ Physical Therapist’s Report (Forms OT/PT-4, EOT/PT-4)
Psychologist’s Report (Form PS-4)
Attending Ophthalmologist’s Report (Form C-5)

Forms Not Replaced by the CMS-1500 Form
Doctor’s Report of MMI/Permanent Impairment (Form C-4.3)

 

CMS 1500 requirements

• The CMS 1500 form has to be filled in accurately for every service provided to patients covered by the WCB.
• A medical narrative and attachments must accompany each claim on a CMS 1500 form (1). Without these, the submission is not considered valid.
• The board has specific technical requirements for electronic claims submission (http://www.wcb.ny.gov/content/ebiz/XMLSchemas/XMLoverview.jsp). These are additional to the requirements of the payers.
• Your practice needs Provider registration with the Board to start submitting CMS 1500 form.
• Even if you are registered for EC-4NARR, you must re-register for submitting in CMS1500 XML.

CMS-1500 Form XML Submission Process

You can do it yourself, or you can involve a submission partner. Either way, the claim, narrative and attachments go to the payer. On receiving these, the payer sends acknowledgement to you or your submission partner. Your submission partner sends you this acknowledgement for your records. They then send Form CMS-1500, narrative/attachments, and acknowledgement of receipt to the Board.
The payer and the Board will initiate their internal processes, leading to your reimbursement.

Timelines of CMS-1500 submission

The initial submission must be done within 48 hours of initiating treatment.
The subsequent submission should be done within 15 days.
Follow-up consultations or treatment require submission again.

CMS 1500 claim form instructions

Once you are a Board Authorized Provider, you should complete an XML Submission Agreement. This will allow you to submit claims to the Board electronically (2).

The clearinghouse being used must also be approved by WCB as an XML submission partner. Approval means that the business has proven that it has the technical capabilities to submit EC-4NARR data to the Board in XML file format.

A TIFF-formatted medical narrative and images of the completed CMS-1500 are also required. These should be of good quality and clearly legible.

Advantages of electronic submission

Currently, the board is accepting paper submissions also for CMS-1500 forms. However, submitting electronically has several advantages
• Accurate and error-free claims data.
• Faster submission and quicker reimbursement.
• Verifiable acknowledgement on submission. This shows when the bill was received by the payer. It is mandatory for the payer to remit payment within 45 days from the acknowledgement date.

The WCB had unique forms that required special effort from providers. The change to CMS-1500 benefits healthcare providers; most are already familiar with this form. It’s used almost universally by payers.

Summary

The Worker’s Compensation Board is particular about its requirements and processes. In early 2021, XML submission of CMS 1500 form will become mandatory. In light of this, it’s best to move from the older forms to the CMS-1500 form right away. Early adoption will help you to iron out the difficulties and be ready for the big day.
Now, making the transition might be somewhat troublesome and time-consuming for you. But you can always partner with a medical billing company that is ready with all the technology and approvals needed to process your claims smoothly and quickly. This will keep your workflow intact and result in faster reimbursements without any hassles.

 

References
1. CMS-1500 Initiative – The New York Worker’s Compensation Board. http://www.wcb.ny.gov/CMS-1500/
2. CMS-1500 Initiative – Frequently Asked Questions. http://www.wcb.ny.gov/CMS-1500/faqs.jsp

 

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