CMS-Form 1500

New York State Workers’ Compensation

Changes in New York Workers Compensation Regulation:

To improve healthcare participation of the providers in the New York State workers compensation system and to improve the condition of injured workers/employees’ access to timely and quality medical care, the New York State Workers Compensation Board (WCB) has decided to adopt Form CMS-1500. This Form is already been used by all insurance carriers and medical providers. It is the standard claim form used to bill health payers as well as the Centers for Medicare and Medicaid Services (CMS). This initiative will leverage a provider’s current medical billing software and medical records while promoting a more effective workers compensation system.

Implementation of Form CMS-1500 will allow the Board to consolidate and remove certain medical billing forms, thereby reducing the administrative difficulties on health care providers.

The Board will replace the following forms with Form CMS-1500:

  • 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)
  • Attending Ophthalmologist’s Report (Form C-5)

The XML Forms Submission project: is built to allow the submissions of information to the Workers Compensation Board in an industry standard XML format. Initially, only claims related medical information were supported. A similar method will be implemented to submit the CMS-1500 form and applicable narratives/attachments.

CMS- 1500 XML Submission and Validation criteria:

Submissions of data should consist of a single compressed archive in ZIP format containing one XML file and zero or more binary attachments.  Attachments must be in binary format as a TIFF image. Text attachments are also supported, but these will be embedded in the XML file itself.

The submissions will be transmitted to the Workers’ Compensation Board (“WCB”) via an encrypted browser connection. Upon submissions of the files, the below validations are performed:

  • Is the ZIP file valid?
  • Is the included XML file valid (does it conform to the schema?)?
  • Is the set of included TIFF files complete (any missing or unreferenced?)?

Upon completion of the testing of each document, one of three statuses will be assigned. Below are the three statuses:

  • Accepted: Processed without errors or warnings (there is no text message associated with this status)
  • Accepted with Errors: Processed, but there was a problem with some aspect of the document (the associated text message will provide detail)
  • Rejected: Not processed (the associated text message will provide detail)

Upon completion of submission processing, results will be made available to the business partner for download.

Workers’ Compensation is a form of insurance paid by companies/employers. No payroll deductions are taken from employee’s salaries for this insurance. If an employee acquires a work-related illness or he is injured on the job, then workers compensation will pay the employee’s medical expenses, and if he/she can’t work, it will also cover wage-loss compensation until the employee is able to return to work.

Funds/benefits are usually paid by a private insurance company or state-run workers compensation fund. It also provides benefits to the dependents if a person dies as a result of a job-related injury/illness.

Workers’ Compensation Board (WCB): Agencies which are formed by the provincial governments, the Worker’s Compensation Board exists in the field of workplace safety to help employers, workers, and health care providers alike in the area of workers compensation for injury recovery, including benefits, employer services, and research.

The WCB’s role

Workers compensation board provides a system where information and services help companies manage insurance coverage. They provide funds to employees/workers to allow them time to heal the injury/illness and come back to work and also provide funds to ensure workplace accidents are paid by Employers and not by Employees.

 

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Keerthi Chavva
Healthcare Consultant Keerthi is a subject matter expert at Nalashaa with hands on experience on different clinical and billing workflows, analyzing and embedding different regulations within regular workflows, identifying solutions that improves care and helps providers with a better A/R outcomes. Also passionate about creating generalized solutions that indicates providers from multiple perspectives w.r.t different regulatory programs.
Keerthi Chavva

Latest posts by Keerthi Chavva (see all)

Keerthi Chavva
Keerthi Chavva

Healthcare Consultant Keerthi is a subject matter expert at Nalashaa with hands on experience on different clinical and billing workflows, analyzing and embedding different regulations within regular workflows, identifying solutions that improves care and helps providers with a better A/R outcomes. Also passionate about creating generalized solutions that indicates providers from multiple perspectives w.r.t different regulatory programs.

All stories by: Keerthi Chavva