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Attention NY Workers Compensation Providers, New HCFA-1500 (CMS 1500) Rules

Starting January 1, 2019, New York workers’ compensation providers may submit original bills using the CMS 1500 form, rather than New York-specific forms C-4, C-4.2, OT/PT-4, PS-4, and C-AMR. Providers nationwide use the CMS 1500 to bill Medicare and group health plans for professional services.

But while the CMS 1500 is a universal billing form, workers’ comp differs significantly from Medicare and group health. The New York Workers’ Compensation Board (WCB) will therefore impose specific requirements for properly completing this form in a workers’ comp context.

Form Requirements

To ensure proper reimbursement, it’s crucial to fill out the CMS 1500 completely and accurately. New York providers must complete the CMS 1500 form as directed by the WCB’s Field Table Matrix (available on the CMS-1500 Initiative webpage), pictured below.

Column A identifies the corresponding field on the CMS 1500 form. The subsequent columns provide instructions on completing each field. For example, the red box below highlights the instructions for field ‘0’.

CMS 1500 Column A

Column B features a description of the field, the information providers must include within the field, and the order in which the information should appear.

Column C indicates whether the information for the field is:

  • Required (R)
  • Situational (S)
  • lI>Optional (O)
  • Not Applicable (N)

Naturally, providers must include information for any field marked “R.” For fields marked “S,” providers must only include the information if the situation meets the requirements described in Column D, which describes the specific information providers must include in a given field if further explanation is necessary.

Column E indicates whether a given piece of data is Numeric (N) only or Alpha/Numeric (A/N). Where Column E lists “None,” providers should leave the field blank, or in the case of Field 31, provide a signature. The provider’s signature may be signed, typed or stamped.

Column F indicates the maximum number of characters which may be included in the field.

These requirements are applicable to both the paper CMS-1500 form and its electronic equivalent.

The CMS-1500 Initiative webpage also provides a sample of a properly completed CMS 1500. Below, all of the information listed for Field 0 appears in the red box.

CMS 1500 Example

In addition to the CMS 1500 form, providers will also be required to submit certain attachments to support their charges. In future blog posts, we’ll discuss these attachment and reporting requirements.