Medical and Billing Form Updates/Clarifications (08/13/20)
As of January 1, 2020, licensed clinical social workers, nurse practitioners and acupuncturists, as well as physician assistants, occupational therapists and physical therapists can be authorized to treat injured workers in New York State. Going forward, only those providers who are Board authorized may treat workers’ compensation patients.
As the NYS Workers’ Compensation Board works to integrate newly authorized providers into the New York State workers’ compensation system, there are some important clarifications to note regarding the use of the following medical and billing forms.
- CMS-1500
- Doctor’s Initial Report (Form C-4)
- Doctor’s Progress Report (Form C-4.2)
- Doctor’s Report of MMI/Permanent Impairment (Form C-4.3)
- Attending Doctor's Request for Authorization and Carrier's Response (Form C-4 AUTH)
- Doctor’s Narrative Report (Form EC-4NARR)
- Attending Doctor's Request for Approval of Variance and Carrier's Response (Form MG-2)
- Occupational/Physical Therapist’s Report (Form OT/PT-4)
- Occupational/Physical Therapist’s Report (Form EOT/PT 4) (online version)
- Psychologist’s Report (Form PS-4)
Terminology
Until the terminology on the forms can be amended, the terms “doctor” and “physician” should be read as “medical provider.”
CMS-1500 and Medical Narrative
All medical providers are encouraged to use the CMS-1500 form (paper version) with an attached medical narrative report, but the current forms may continue to be used. Medical providers can submit supporting clinical documentation (which includes the required legal language regarding causation) on the medical narrative report and attach it to the CMS-1500 instead of using the current Board forms. (The Board has recently released a medical narrative template that should be used to create the medical narrative report.)
Use of Current Board Forms by Provider Type
Some of the current Board forms and XML submission of certain forms are permissible for certain provider types only, as shown in the chart below.
| Provider Type | Form/XML Usage | ||
|---|---|---|---|
| CMS-1500 plus NARR | Board Forms | XML | |
| Physician | Yes | Form C-4, C-4.2, EC-4NARR | EC-4NARR |
| Nurse Practitioner | Yes | Form C-4, C-4.2, EC-4NARR | EC-4NARR |
| Physician Assistant* | Yes | Form C-4.2, EC-4NARR | EC-4NARR |
| Podiatrist | Yes | Form C-4, C-4.2, EC-4NARR | EC-4NARR |
| Chiropractor | Yes | Form C-4, C-4.2, EC-4NARR | EC-4NARR |
| Psychologist | Yes | Form PS-4, EC-4NARR | EC-4NARR |
| Licensed Clinical Social Worker | Yes | Form C-4, C-4.2, EC-4NARR | EC-4NARR |
| Physical Therapist | Yes | Form OT/PT-4, EOT/PT-4 | EOT/PT-4 |
| Occupational Therapist | Yes | Form OT/PT-4, EOT/PT-4 | EOT/PT-4 |
| Acupuncturist | Yes | N/A | NONE |
The Board’s forms for prior authorization requests and opinions on permanency are permissible for certain provider types only, as shown in the chart below.
Forms for Prior Authorization Requests & Opinions on Permanency
| Provider Type | Form C-4 AUTH/MG-2 | Permanency Opinions |
|---|---|---|
| Physician | Form C-4 AUTH/MG-2 | Form C-4.3 |
| Nurse Practitioner | Form C-4 AUTH/MG-2 | Form C-4.3 |
| Physician Assistant* | Form C-4 AUTH | N/A |
| Podiatrist | Form C-4 AUTH/MG-2 | Form C-4.3 |
| Chiropractor | Form C-4 AUTH/MG-2 | Form C-4.3 |
| Psychologist | Form C-4 AUTH/MG-2 | Form C-4.3 |
| Licensed Clinical Social Worker | Form C-4 AUTH/MG-2 | Form C-4.3 |
| Physical Therapist | Form C-4 AUTH | N/A |
| Occupational Therapist | Form C-4 AUTH | N/A |
| Acupuncturist | Form C-4 AUTH | N/A |
*All Physician Assistant services must be performed under physician supervision.
To receive updates about availability of online forms and XML submissions, sign up for WCB Notifications.
Nurse Practitioner Authorization Numbers
While Nurse Practitioners (NPs) are among those providers who can use Form MG-2 to request a variance from the Medical Treatment Guidelines, the space on the form for authorization numbers is formatted differently than the actual NP authorization number. An NP may enter his or her authorization number into Form MG-2 even though the formatting is different. This is not a defect in Form MG-2, and the Form MG-2 should be processed to evaluate the medical necessity for the treatment requested.
Example:
NP’s authorization number: N987654-3
Formatted for Form MG-2: N98765-43
More Information
For more information and resources related to the Expanded Provider Law, please visit the Expanded Provider Law web page.
If you have any questions about WCB medical and billing forms, please contact the Medical Director’s Office at WCBMedicalDirectorsOffice@wcb.ny.gov.
