The initiative is rolling out in three phases, as follows:
Phase 1 – Voluntary Submission (Current Phase)
The first XML Submission Partner was approved in February 2020. As additional XML submission partners are approved, they will be added to the List of approved XML Submission Partners.
- Providers may voluntarily transmit CMS-1500 medical bills (and required medical narratives, and/or attachments as applicable) through their clearinghouses (XML submission partners) to workers' compensation payers: insurers, third-party administrators or self-insured employers.
- The CMS-1500 must be submitted with a detailed narrative report to be considered a valid submission. Guidance on Required Medical Narratives and Attachments
- To participate in the initiative, providers must register with the Board to submit the CMS-1500 via an XML (extensible markup language) format. Providers may register on the Board's website on the health care provider registration page at any time.
- XML submission partners interested in submitting to the Board must also register by contacting the Board. All XML submission partners (both existing and new) must successfully complete testing with the Board to obtain approval to submit the CMS-1500 in XML format. A listing of approved XML submission partners for the CMS-1500 will be posted on the Board's website after each entity successfully completes testing and executes an XML Submission Partner agreement with the Board.
- Workers' compensation payers will accept CMS-1500 medical billing files from XML submission partners and electronically return acknowledgments of receipt of CMS-1500 files. Such acknowledgments (including receipt date) will be forwarded from the XML submission partners back to providers and the Board.
- The Board will receive CMS-1500 files, narrative attachments, and payers' acknowledgment of receipt from XML submission partners, in a designated XML format. The CMS-1500 forms and narrative attachments received by the Board will be combined and displayed in the applicable claimants' WCB case folders.
- The XML submission partners will be required to be submit CMS-1500 and narrative reports to the Board within seven business days of receipt from the provider. When a CMS-1500 form and narrative report is not accepted by the payer within three business days, the XML submission partner will be required to advise the provider and seek direction as to whether to continue electronic submission attempts or submit the CMS-1500 and narrative report in paper format. The reporting requirements of the Workers' Compensation Law and its regulations, specifically 12 NYCRR §325-1.3, remain unchanged. Providers (and XML submission partners on behalf of providers) are required to remain compliant with these reporting requirements.
Phase 2 Updated – Explanations of Benefits (EOB) Transmittal (2021)
The Board will not require payers to send electronic EOBs to the Board as previously planned. Instead, Phase 2 will require payers to use specific Claims Adjustment Reason Codes (CARC) on their provider EOBs when objecting to payment of a medical bill. Listing of CARCs and additional guidance: Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs)
- Workers' compensation payers will electronically transmit Explanations of Benefits (EOB) to their XML submission partners upon adjudication of the associated electronic CMS-1500 medical bills. Such EOB data will be forwarded from the XML submission partners back to providers.
- Payers will be required to use specific Claims Adjustment Reason Codes (CARC) on their provider EOBs when objecting to payment of a medical bill.
- The Board may eventually eliminate the requirement for the payer to file Notice of Treatment Issue/Disputed Bill (Form C-8.1B) or Notice to Health Care Provider and Injured Worker of a Carrier's Refusal to Pay All (or a Portion of) a Medical Bill Due to Valuation Objection(s) (Form C-8.4) to object to full or partial payment of a medical bill when an EOB for the medical bill with required CARC codes was transmitted to the provider. The provider may file Health Provider's Request for Decision on Unpaid Medical Billing (Form HP-1) based on receipt of the EOB with required CARC codes.
Phase 3 – Mandatory Submission (2021)
- Providers will be required to submit electronic CMS-1500 medical bills (and required medical narratives, as applicable) through their XML submission partner to workers' compensation payers and to receive EOBs back through their XML submission partner. The XML submission process will be the same as described in Phases 1 and 2.
Providers will be required to electronically transmit any disputes for unpaid medical bills to their XML submission partner using the Board-prescribed form. The XML submission partner will electronically transmit medical disputes to the Board in a designated XML format. The Board will eliminate the following forms:
- 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)
- Ophthalmologist's Report (Form C-5)
Web submission and XML submission of these forms will no longer be available.