Subject Number 046-1707

Electronic CMS-1500 Initiative Update for Providers

Board Bulletins and Subject Numbers

As part of the New York State Workers' Compensation Board's (Board's) ongoing modernization initiatives, the Board will require health care providers to contract with an electronic submission partner to submit the CMS-1500 universal medical billing form electronically on their behalf beginning in 2025.  In 2022, the Board transitioned to the CMS-1500 to reduce the administrative burden on health care providers.  This new requirement will allow for greater accuracy, efficiency, and data reporting capabilities and align with the Board's goal of moving many paper processes online.  The CMS-1500 electronic submission requirement for providers will become mandatory on August 1, 2025.  As of that date, the Board will not take action on or enforce payment of a bill submitted on a paper CMS-1500 form.  Forms that are submitted prior to August 1, 2025, will continue to be processed, but providers are encouraged to transition to electronic submission well in advance of the mandatory date, in order to reduce the likelihood of submissions being "lost" in the transition.  Providers should keep these additional points in mind with the new requirement:

• Providers will still have the ability to submit a paper CMS-1500 form to the electronic submission partner (who will then submit it electronically to the Board on the provider's behalf).
• Payment may be denied when a bill is submitted improperly (i.e., not submitted electronically through an approved electronic submission partner).
• Providers decide which electronic submission partner they want to use.  Costs and services may vary by company.  View the Board's list of approved electronic submission partners.
• Providers will have the ability to offset the cost of using an electronic submission partner by using code 99080, previously a "No Charge" (NC) code defined in the Official New York Worker's Compensation Medical Fee Schedule as "Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form," which may be used as a "By Report" (BR) code, up to a maximum value of one dollar.  The code should be placed on the same CMS-1500 form for which the billable services payment and the electronic submission costs are being requested.  The price listed by the provider for code 99080 should accurately reflect the actual cost incurred by the provider for the electronic submission of the individual bill, up to a maximum of one dollar.
• Providers are strongly encouraged to use the narrative template to create the medical narrative report that must be submitted with the CMS-1500 for ease of locating the essential elements of: causal relationship; work status; and impairment/disability level.  For those using their own template, please remember to include these elements in a highly visible location on your reports.

Submitting the CMS-1500 electronically has significant benefits, including:

• Faster payment.
• Reduced administrative burden (electronic submission partner submits the CMS-1500 to the insurer and the Board).
• Certainty created with electronic acknowledgement of insurer's receipt of the bill (removes need to resubmit bills), plus confirmation of acceptance or rejection of the bill within seven days.
• Faster identification and correction of technical errors, and quicker resubmission (no waiting until insurer denies the bill).
• No cost or low cost.

Please contact the Medical Director's Office at MDO@wcb.ny.gov if you have any questions.