Workers’ Compensation Provider Billing FAQs

A workers’ compensation provider, which can be a doctor, hospital, or another healthcare professional, offers services to injured workers covered by the Workers’ Compensation Law.

Billing-related terminology might seem complex, and this section aims to address common questions, particularly following New York state workers’ compensation guidelines.

If you’re billing for services unrelated to workers’ compensation, it’s crucial to separate those charges from claims submitted to your insurance company. For instance, if you’re filing a claim for an injured worker but also treating them for a condition like diabetes, billing should be separated. This ensures that only the portion related to their injury is covered by workers’ compensation insurance benefits, not their health insurance plan.

Do all CMS-1500 submissions require a medical narrative or form attachments? Yes, all CMS-1500 forms require a medical narrative or attachments when submitted through various channels, including clearinghouses, XML submission partners, or directly to the Workers’ Compensation Board. The Board provides a medical narrative report template to accompany each provider’s CMS-1500 submission.

Does the CMS-1500 replace the C-4.3 form? No, the CMS-1500 does not replace the C-4.3 form.

Does the Workers’ Compensation Board accept a paper CMS-1500 form? Yes, the Workers’ Compensation Board does accept a paper CMS-1500 but strongly encourages electronic submission via the XML submission process.

How can I submit the CMS-1500 form using the XML submission process if my clearinghouse is not registered as a Workers’ Compensation Board XML submission partner? Clearinghouses interested in becoming XML partners need to register with the Workers’ Compensation Board. Submission partners must then go through testing for approval in the CMS-1500 XML submission process before implementation. Alternatively, clearinghouses can work with an approved XML submission partner if they prefer not to become a direct submission partner.

For additional billing information, the medical provider can obtain the patient’s employer’s details. If uncertain about the correct employer, patients can contact their human resources office or supervisor. New York state employers are required to display the Notice of Compliance – Workers’ Compensation Law (Form C-105) in the workplace, providing information about the correct employer’s Workers’ Compensation insurance carrier name, address, phone number, and policy number. Additionally, providers can access information using the Employer Coverage Search app on the Workers’ Compensation Board’s website.

What are the specific CMS-1500 requirements for chiropractors? Chiropractors don’t have unique CMS-1500 requirements. However, they must follow the initial and subsequent narrative report requirements of the CMS-1500.

How do I become a Workers’ Compensation Board authorized provider? To become a Workers’ Compensation Board authorized provider, you need to submit an application.

How can I confirm that a clearinghouse is in the process of becoming a CMS-1500 XML submission partner? Check the Workers’ Compensation Board’s published list, which indicates the status of clearinghouses interested, testing, or approved to become a CMS-1500 XML submission partner.

Does the Expanded Provider Law change how I submit the CMS-1500 via XML? The Expanded Provider Law mandates certain healthcare professionals to bill as rendering providers, affecting how they complete the online Medical Portal registration process for XML submission of CMS-1500.

Explain the requirements for the TIFF-formatted medical narrative and image of a completed CMS-1500. Ensure clarity and quality in images submitted in TIFF-4 format with specific requirements, including single-strip images, 200 dpi, black and white with 1-bit color depth, and one image per file.

How should I submit a CMS-1500 for surgery involving another physician, nurse practitioner, or physician assistant? Enter relevant information in Fields 19, 24J, and 31, use Modifier 83 for services by a physician assistant or nurse practitioner, and Modifier 80 for surgery assistant services by another physician. Include details of the surgical assistant provider in the medical narrative.

Which methods are acceptable for sending the CMS-1500 to the XML submission partner? Providers can submit the CMS-1500 to the XML submission partner through various mutually agreeable methods, including EDI, mail, fax, email, or portal.

What is the process if I receive acknowledgment of a paid bill but haven’t received payment? If you don’t receive payment after 45 days of acknowledgment, submit a Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0) through the OnBoard online system.

What are the specific requirements for durable medical equipment (DME) supplies when submitting a CMS-1500? DME suppliers must include their eight-digit Medicaid Management Information System (MMIS) number in Field 24J of the CMS-1500 or the medical narrative attachment.

Who needs to register for XML submission if we’re a small medical practice using a third-party administrator for Workers’ Compensation bills? The treating provider, not the third-party administrator, must register for XML submission.

Do all providers have to be authorized by the Workers’ Compensation Board to submit the CMS-1500? No, certain providers, such as urgent care, emergency department, out-of-state, and DME providers, aren’t eligible for Workers’ Compensation Board authorization. However, they must register for XML submission through an XML submission partner.

Where should the second ordering provider’s information apply on the CMS-1500 if there are two different ordering providers? One provider enters information in Fields 17, 17a, and 17b, while the second provider includes their details in the attached medical narrative.

When will I know if the payer accepted my bill? You’ll receive verifiable acknowledgment data upon electronic submission, indicating the payer received the bill. The payer must remit payment within 45 days.

What are the required timeframes for submitting medical reports? Follow the timeframes outlined in NYCRR 325-1.3, submitting the initial CMS-1500 within 48 hours of initial treatment and subsequent CMS-1500 within 15 days after initial treatment and for continuing treatment.

Do all payers accept CMS-1500? Yes, all payers must accept CMS-1500 submissions in various formats, including paper, electronic, EDI, or other mutually agreed formats.

Can providers access patient medical records through clearinghouses? Clearinghouses provide services to medical providers, but access to patient medical records depends on the specific services offered by the clearinghouse.

Do clearinghouses use medical records from Medicare, Medicaid, or private insurers to dispute WCB claims? The CMS-1500 initiative doesn’t endorse data sharing outside the Workers’ Compensation system. Providers must not simultaneously bill Workers’ Compensation payers and insurers for the same service, following Workers’ Compensation Law 13(a), which requires prompt provision of services to injured employees by employers.

Where do I put the provider’s WCB authorization number and rating code on the CMS-1500? Enter the authorization number and rating code in Field 19 on the CMS-1500.

Are medical narrative attachments necessary for patients with a lifetime approved benefit? Yes, all medical bills require narrative attachments, regardless of the patient’s permanent classification.

Can I manually upload medical narratives on the Workers’ Compensation Board website? Certainly, the Workers’ Compensation Board website has a section to manually upload medical reports.

Do I have to use the same clearinghouse as the payer for electronic submissions? No, you’re not obligated to use the same clearinghouse as the payer. Clearinghouses often have multiple agreements to ensure efficient electronic bill submission.

If a bill gets rejected, can I bill the patient? No, according to Workers’ Compensation Law Section 13-f, you cannot bill the patient if the payer rejects the bill.

When can I submit the initial medical bill or report to the payer and the Workers’ Compensation Board? Submit the bill or report based on medical decisions, typically after the initial treatment for a reportable Workers’ Compensation injury beyond first aid.

Are changes needed for proprietary data elements due to X12 837 lack of support? No, your existing workflow remains unchanged. The XML submission partner processes data for WCB Rating Code and Authorization Number alignment with the CMS-1500.

Are there attachment format changes for Property and Casualty Commercial payers? No, approved XML submission partners ensure attachment format conversion compliance with Workers’ Compensation Board requirements.

When is the CMS-1500 used?The CMS-1500 is a standard claim form for medical providers billing Medicare, Medicaid, and health insurers.

Can a rejected CMS-1500 result from a casual relationship, and how does the Workers’ Compensation Board judge work-related causation? A rejected CMS-1500 may happen if the mandatory elements in the medical narrative report—patient’s work status, causal relationship, and temporary impairment percentage—are missing. The payer’s assessment of a casual relationship remains separate.

Can I use the CMS-1500 for medical testimony billing? Utilize CPT code 99075 on the CMS-1500 for medical testimony. Medical testimony billing operates outside the standard 45-day payment period, and there’s no specific CARC code or objection process.

Do electronically submitted CMS-1500 forms need to go to the Workers’ Compensation Board? No, electronic CMS-1500 submissions through an XML submission partner go directly to the payer and the Workers’ Compensation Board.

What if a provider omits information from the CMS-1500 narrative? Omitting mandatory elements, like the patient’s work status or causal relationship, makes the CMS-1500 legally defective.

Can an occupational or physical therapist indicate a temporary impairment percentage on the CMS-1500? No, occupational and physical therapists don’t provide information on causal relationships or temporary impairment percentages.

Does the Workers’ Compensation Board still accept faxed claims? No, the Board no longer accepts faxed claims. However, claims are accepted through electronic submission, XML partners, mail, email, or web upload.

Is there a list of payers not accepting electronic claims? All Workers’ Compensation payers must accept electronic CMS-1500 submissions, EDI, or other mutually agreed formats starting October 1, 2021.

Are specific narrative requirements needed for daily progress notes with CMS-1500 submission? Yes, the Workers’ Compensation Board’s CMS-1500 Requirements page outlines the necessary details for the medical narrative attachment.

How can I electronically submit attached medical narratives? Coordinate with your XML submission partner to format the electronic submission compliant with Workers’ Compensation Board requirements.

Can I use a SOAP note for the CMS-1500 re-exam if it lacks mandatory elements? The CMS-1500 requires a complete medical narrative with mandatory elements—patient’s work status, causal relationship, and temporary impairment percentage. Failure to include these elements may render the medical narrative legally defective.

Can providers hire their XML submission partner, or does the insurance company choose? Providers should partner with an approved XML submission partner to ensure proper submission to the appropriate payer.

Is there a penalty for not using an XML submission partner? No penalty exists, but using an XML submission partner is recommended for efficient processing.

Must DME suppliers use a CMS-1500 and provide a medical narrative even without patient examination? Yes, DME suppliers must use the CMS-1500. Attachments should include a copy of the physician’s prescription and proof of enrollment certification in the NYS Medicaid program.

If I submit a paper CMS-1500, do I need to register for the Medical Portal? Yes, it’s advisable to register for the Medical Portal for various benefits, including access to training, updating practice information, and submitting CMS-1500 bills through an XML submission process.

Does the CMS-1500 replace the C-4.3, and can I submit the C-4.3 electronically? The CMS-1500 doesn’t replace the C-4.3. You can submit the C-4.3 electronically using the CMS-1500 with specific guidelines.

If the CMS-1500 paper version has more than six items, how should I handle it? Submit multiple CMS-1500 forms if there are more than six line items for one service date. The total charge should appear on the last form.

How do I electronically submit bills for apportioned claims? Clearly state the apportioned bill in the medical narrative attachment and provide other relevant case and carrier numbers.

For more information, check your state’s Workers’ Compensation Board website or consult a Workers’ Compensation attorney.

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