Board Bulletins and Subject Numbers

January 21, 2021

As part of the CMS-1500 initiative, the Board has updated 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) to clarify potential legal and valuation objections, respectively, 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. With the elimination of Part A, one of the objection reasons currently on Part A of Form C-8.1 that is not obsolete: “Requested treatment is not for an established site or condition” will be moved to Request for Further Action by Carrier/Employer (Form RFA-2); a new version of Form RFA-2 will be published later in 2021. Additionally, Form C-8.1 will be renamed Form C-8.1B. The new forms will become effective on July 1, 2021. After August 15, 2021, the current versions of the forms will not be accepted, and no action will be taken by the Board should an insurer continue to use them. Only the new forms, dated July 2021, will be accepted.

Standardized Objection Reasons: As previously announced, effective July 1, 2021, insurers will be required to use Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) on an explanation of benefits (EOB) sent to a health care provider to object to payment of a medical bill. The insurer 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 have been updated to include the associated CARC and RARC codes.

Crosswalk of Objection Reasons to CARC Codes

A new objection reason has been added to Form C-8.1B to allow insurers to object to a medical bill if it is not sent in an electronic format (CARC P13, RARC M117). This objection reason will be valid once the provider’s grace period for electronic submission of Form CMS-1500 expires on August 15, 2021, unless the provider has been granted a waiver by the Board. Thus, insurers may commence using this objection reason for any bills submitted by providers on or after August 16, 2021.

Insurer Objection Period: Insurers must remit payment or object to payment of the bill within 45 days from when the bill is received by the insurer. The acknowledgement date on the Form CMS-1500 (field 19) is the start date for the 45-day period. If the bill is not electronically submitted, the 45-day period will start on the date the bill was received by the Board. Insurer Notice to Providers: Insurers 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:

• Insurer’s name
• Claimant’s name
• WCB Case Number
• Claimant DOB
• 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.