Yes, you can bill for DME items or services using the CMS-1500 form. The Board has provided specific examples of using Form CMS-1500 for the billing of DME items. A separate billing using Form CMS-1500 is required if you are billing for DME items using your DME supplier license. Provide the NPI number for the DME entity in Form CMS-1500 and the required MMIS ID# in the attachment. Alternately, if billing using EDI, the MMIS ID# may be included in field 24J (shaded area) of the Form CMS-1500, along with qualifier "OB."

Out-of-state health care providers providing medical services to injured workers residing outside of NYS are exempt from completing field 24J (shaded area) above.

Yes, the facility can bill for DME items or services using Form CMS-1500. The Board has provided specific examples of using Form CMS-1500 for the billing of DME items. Provide the facility NPI in Form CMS-1500 and the MMIS ID# in the attachment. Alternately, if billing using EDI, the MMIS ID# may be included in field 24J (shaded area) of the Form CMS-1500, along with qualifier "OB."

Out-of-state health care providers providing medical services to injured workers residing outside of NYS are exempt from completing field 24J (shaded area) above.

In the event of a medical emergency requiring immediate use of DME following an accident or injury, exacerbation of an earlier accident, or injury or unanticipated results following surgery, DME items may be dispensed without prior authorization.

The health care provider shall submit the bill for the DME together with a description of the emergency and justification of the need, along with the submission of the appropriate medical bill/report.

Inappropriate identification of a need for emergency DME by a health care provider may result in imposition of penalties by the Board.

Per the new DME fee schedule, hearing aids require a prior authorization request (PAR); audiologists are eligible to submit DME PARs;

Audiologists are required to bill for audiology services/items using the Form CMS-1500. Electronic billing is preferred. Specific examples of using Form CMS-1500 for the billing can also be found on the Board's CMS-1500 requirements web page.

Audiologists are also required to provide documentation of audiologic test battery results, based on the Record of Percentage Hearing Loss (Form C-72.1).

Optometrists are eligible to submit DME PARs. For example, contact lenses and glasses are DMEs requiring PARs pursuant to the new DME Fee Schedule.

Optometrists are required to bill for optometric services/items using the Form CMS-1500. Electronic billing is preferred. Specific examples of using Form CMS-1500 for the billing can also be found on the Board's CMS-1500 requirements web page.

Optometrists are also required to provide a detailed SOAP note reflecting history, exam, assessment and plan of care consistent with accepted optometry documentation standards.

Supplies that are customarily included in surgical packages, such as gauze, sponges, Steri-strips, and dressings; drug screening supplies, and hot cold packs are included in the fee for the medical services in which such supplies are used and should not be billed separately.

Prior authorization may not be required for the same item. It is at the discretion of the insurer of whether to repair or replace. If the item requires a PAR per the DME Fee Schedule, it would be in the best interest of the provider to submit a PAR requesting repair or replacement of said item, along with documentation supporting the repair or before providing a new item.

No. The Workers' Compensation Law does not permit a provider of health care to collect from, or bill, an injured worker for services rendered, unless a decision is issued by the Board indicating that the injured worker failed to prosecute their claim, the claim is denied, the treatment is not causally related to the work injury, or a Section 32 agreement has been approved relieving the insurer of liability for medical expenses.

All DME items used when an injured worker is in an inpatient status are included in the All Patients Refined Diagnosis Related Groups (APR-DRG) reimbursement. Medically necessary and appropriate DME items required for a safe discharge/transition to home following an inpatient stay are reimbursed in accordance with the DME Fee Schedule. All DME items used when an injured worker is at an ambulatory surgery center, emergency room, rural clinic or hospital-based mental health clinic are included in Enhanced Ambulatory Patient Groups (EAPG) methodology reimbursement.

These DME items do not require prior authorization.

When a health care provider recommends DME that is not listed in the DME Fee Schedule, prior authorization, including a proposed purchase price or rental price for such equipment, must be obtained prior to prescribing or supplying such DME. The PAR must be submitted by the appropriate health care provider.

DME items should be prescribed subject to medical necessity and should be appropriate for the medical condition of the injured worker. Providers should review the MTGs for the appropriateness of DME items for relevant body parts. The Board does not recommend specific DME items for specific medical conditions and relies on the medical necessity as stated/documented by the health care provider for the prescribed DME item.

All Board-authorized providers must use OnBoard to request prior authorization for DME items.

No, you should NOT request prior authorization for any DME item that does not have a "Yes" in the PAR Required column and is being provided consistent with the MTG recommendations.

The PAR process is the means by which Board-authorized health care providers will use the Board's web application, OnBoard, to obtain approval to prescribe treatment, medical supplies or services, or medications not included in applicable MTGs, Fee Schedules, or the Drug Formulary. A DME PAR will be required prior to prescribing DME items that are not included, or have "Yes" in the PAR Required column, on the DME Fee Schedule or are not consistent with MTG recommendations.

The insurer shall approve, grant in part, or deny a prior authorization request within four calendar days of submission by a provider.

Grant in part (referred to as "partial approval" in the Workers' Compensation Law) means that the insurer:

1. authorizes DME with a different HCPCS code than was requested; or,
2. when a rental was requested, authorizes rental of the requested DME for less than the requested duration; or
3. authorizes DME not listed on the DME Fee Schedule at a lesser purchase price than requested by the health care provider; or when the insurer approves rental of DME instead of purchase of such equipment.

If, and only if, the insurer's physician issues a denial or a grant in part, the health care provider may seek review by the Board's Medical Director's Office.

All requests for review of a denial or a grant in part of a prior authorization request shall be submitted to the Medical Director's Office through OnBoard.

The health care provider shall submit the request to the Medical Director's Office through OnBoard within 10 calendar days of the denial date together with all documentation submitted in support of its PAR, and the denial or grant in part issued by the insurer's physician. Providers should include a rebuttal to the carrier's denial rationale and any additional relevant information in the free text "Escalation Reason" field before escalating to the MDO in the system.

The Medical Director's Office (or designated accredited entity) decision is final and binding for the health care provider and the insurer under Workers' Compensation Law section 23.

If the PAR is denied on the merits, the health care provider may not submit a request for prior authorization for the same DME unless they submit evidence that there has been a change in the injured worker's medical condition that renders the denial of the request for prior authorization no longer applicable to the injured worker's current medical condition. If your patient would like to appeal this determination, either they or their legal representative may file a Form RFA-1W or Form RFA-1LC respectively.

A request for prior authorization that is not responded to within four calendar days (by an approval, denial or grant in part) may be approved upon the Board's issuance of an Order of the Chair (OOC) and the insurer shall be subject to a penalty pursuant to section 25(3)(e) of the Workers' Compensation Law. An insurer may not object to payment in accordance with Title 12 NYCRR 325-1.25 for DME approved by an OOC and any such objection or non-payment may be subject to penalties pursuant to section 114-a (3) of the Workers' Compensation Law.

In the event that a PAR is submitted prior to creation of a workers' compensation case by the Board in accordance with Title 12 NYCRR 300.37(a), the prior authorization request will be held by the Board for a period of up to three business days, in order to identify the proper insurer. Upon such identification, the prior authorization will be submitted by the Board and the insurer shall have four calendar days to approve, grant in part, or deny the request.

When an injured worker requires a DME item that is not consistent with the MTGs, the provider should follow the variance process.

Possible reasons include, but are not limited to:

• Extend duration of a DME item when an injured worker is continuing to show objective functional improvement.
• Individual circumstances, such as other medical conditions, may delay an individual's response to treatment, or make certain treatment appropriate.
• Actual DME item is not addressed by the MTGs.
• Peer reviewed studies may provide evidence supporting new/alternative DME items.

Yes. The health care provider may submit a DME PAR to request a duration beyond what is recommended under the MTGs, but must document that the injured worker is continuing to show objective functional improvement that includes, but is not limited to, positional tolerances, range of motion, strength, endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures that can be quantified.

No. A Variance PAR can only be submitted by the treating health care provider (physician, nurse practitioner or chiropractor). The treating health care provider will have to follow the variance process to request any extension to the duration of the rental DME item.

No. A PT/OT are not eligible to submit DME PARs - the requesting provider would submit any DME PARs.

Note: Physical and Occupational Therapists will not be permitted to submit PARs for MTG related requests.

Not all DME codes are listed on the DME Fee Schedule. When a health care provider recommends DME that is not listed in the DME Fee Schedule, prior authorization, including a proposed purchase price or rental price for such equipment, must be obtained prior to prescribing or supplying such DME. If prior authorization was not obtained for the DME item, the insurer may object.

To bill for supplies, the DME supplier must submit Form CMS-1500. Specific examples of using Form CMS-1500 for the billing of DME items can be found on the CMS-1500 Requirements web page. The MMIS ID# will be located either on the attachment or in field 24J (shaded area) of Form CMS-1500, along with qualifier "OB."

The insurer must send the Board a timely filed Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B) or Notice to Health Care Provider and Claimant of an Insurer's Refusal to Pay All (or a portion) of a Medical Bill Due to Valuation Objection(s) (Form C-8.4) with the objection reason noted to properly object to such payment. Effective July 2022, Insurers will be required to use the Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) on an explanation of benefits (EOB) sent to a health care provider/DME supplier to object to a medical bill in addition to the Form C-8.1B and/or C-8.4. The CARC/RARC code list can be found on the CMS-1500 CARC-RARC webpage.

In the event of a medical emergency requiring immediate use of DME following an accident or injury, exacerbation of an earlier accident or injury, or unanticipated results following surgery, DME items may be dispensed without prior authorization.

The health care provider shall submit the bill for the DME together with a description of the emergency and justification of the need for the DME.

The insurer may deny payment for the DME on the basis of medical necessity.

Inappropriate denial by an insurer for a need for emergency DME by a health care provider, may result in imposition of penalties by the Board.

A grant in part or denial of a request for prior authorization must:

• Be issued by the insurer's physician (defined in Title 12 NYCRR 441.1(g)) unless:
  1. such request is for DME that is the subject of an earlier PAR that has been denied or has not yet been acted upon;
  2. such request for DME for a case that is closed, disallowed or cancelled, settled via section 32 of the Workers' Compensation Law, or controverted in accordance with Title 12 300.22 (b)(1)(ii) or (c)(1). Such DME PARs may be denied without review by the insurer's physician.
• Provide a specific reason for the denial or grant in part with reference to the specific PAR made by the health care provider.
• When the grant in part reduces the DME price requested by the health care provider, the grant in part must:
  1. identify two sources of the adjusted price, including the address and phone number of the source, and the reason for such adjustment; and,
  2. the prescribed equipment must be available from a supplier a reasonable distance from the injured worker's home or job. If the injured worker lives in a rural area, the supplier must be located within 15 miles of their home or job. If the injured worker lives in a city or village that has at least 2,500 residents, the supplier must be located within five miles of their home or job, or the equipment must be delivered to their home. The supplier must assemble the equipment, ensure it is ready to use without further fittings, and either have it available or deliver it within 48 hours.