Workers Compensation Board will require providers to use an XML partner

Date: June 16, 2021
The Board has a number of important updates regarding the Notice of Treatment Issue/Disputed Bill (Form C-8.1) and 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). These updates, detailed below, include an immediate change to the reporting of Social Security numbers, as well as revisions to the C-8.1 and C-8.4 forms as part of the Board’s transition to the universal billing form, Form CMS-1500. The Board will be issuing new versions of the C-8.1 and C-8.4 forms and has updated the payer implementation schedule related to the CMS-1500 initiative.
Social Security Numbers

• After a recent review of the C-8.1 and C-8.4 forms, the Board has determined it will no longer require inclusion of an injured worker’s full nine-digit Social Security number, effective immediately. Instead, only the last four digits of the Social Security number should be included on the current paper forms. Payers completing the paper version of these forms should provide the last four digits of the injured worker’s Social Security number in the following format: XXX-XX-1234. Each form will be revised to reflect this change at a later date.

CMS-1500 Initiative
The C-8.1 and C-8.4 forms will be updated to clarify potential objections and to eliminate certain obsolete sections currently found on the left side of Form C-8.1, entitled: Part A Notice of Objection Regarding Further or Future Treatment. The objection reason currently listed under Part A of Form C-8.1, “Requested treatment is not for an established site or condition,” will be moved to the Request for Further Action by Carrier/Employer (Form RFA-2); a new version of Form RFA-2 will be published later in 2022. Form C-8.1 will be renamed Form C-8.1B.
The new C-8.1B and C-8.4 forms will become effective July 1, 2022, and will become mandatory 45 days after the effective date. At that point, the current versions of the forms will not be accepted, and no action will be taken by the Board should a payer continue to use them.
Effective October 1, 2021, payers will be required to:

• Have one or more Board-approved XML submission partners designated to electronically accept health care provider medical bills via Electronic Data Interchange (EDI) or another format agreed upon with the XML submission partner.
• Identify all legal and valuation objections to payment of the medical bill at the same time and file such objections using the current versions of the C-8.1 and C-8.4 forms, within 45 calendar days of acknowledgement of receipt of the medical bill (whether on paper or digital).

Effective July 1, 2022, payers must:

• Use the updated C-8.1B and C-8.4 forms to notify the Board of legal and valuation objections, respectively.
• Use standardized objection reasons, also known as Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs), on an Explanation of Benefits/Explanation of Review (EOB/EOR) sent to a health care provider to object to payment of a medical bill. The payer must send the Board (and other required stakeholders) a timely filed Form C-8.1B or Form C-8.4 with the same objection reason(s) noted to properly object to such payment. All objections must be made at the same time. The new forms will be updated to include the associated CARC and RARC codes. RARC and CARC codes with associated objection reasons can be found on the Timeline section of the Board’s CMS-1500 page.

Payer Objection Period: As a reminder, payers must remit payment or object to payment of a medical bill within 45 calendar days from when the bill is received. The acknowledgement date transmitted by the payer to the XML submission partner and also displayed on the Form CMS-1500 (field 19) is the start date for the 45-day period. If the bill is not submitted electronically, the 45-day period will start on the date the bill was received by the Board.
Payer Notice to Providers: Payers have the option of sharing Forms C-8.1B and C-8.4 with providers by offering secure online access to their systems. However, if they choose to do so, they must notify providers via email each time documents are available to be downloaded or viewed. Such emailed notification must include:

• Payer’s name
• Injured worker’s name
• WCB Case Number
• Injured worker’s date of birth
• Date of medical service
• Date of EOB
• Provider’s name
• Provider’s NPI
• Bill amount

Questions regarding use of the new forms or any of the CMS-1500 requirements should be sent to CMS1500@wcb.ny.gov.

****REPRESENTING INJURED AND DISABLED WORKERS SINCE 1989. OFFICES IN BROOKLYN, BRONX & QUEENS***