General FAQs

• When was the Dental Fee Schedule established?

  The Dental Fee Schedule became effective on 3/1/2009.

• What is the current version of the Dental Fee Schedule?

  The current Dental Fee Schedule version is dated March 1, 2009.

Injured Worker FAQs

• I need a dental provider for treatment for a work injury. Where can I find a list of dental providers in my local area?

  The Board does not authorize dental providers and does not provide lists of dental providers as referrals. You can contact any dental provider in your local area to perform workers’ compensation dental service. You can perform a search on the internet or use local telephone resources. You can also contact the NY Dental Association to find a dentist.

• My dental provider does not want to treat and/or accept workers’ compensation patients. Is this allowed?

  Yes, any dental provider can refuse to treat a workers’ compensation patient for dental services. You can find any other dental provider that is willing to perform this service and accept the Dental Fee Schedule.

• I had to pay for some of the dental expenses out‐of‐pocket. What should I do?

  Please contact the Medical Director’s Office at 1-800-781-2362 or provider@wcb.ny.gov

Dental Provider FAQs

• Does OnBoard affect dental providers?

  OnBoard is an application that is accessed from the Medical Portal. OnBoard: Limited Release is the first phase of OnBoard, designed to move key processes for health care providers and claim administrators from paper to online, including the submission of Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0) and the prior authorization request (PAR) process for medication, durable medical equipment and medical treatment/testing.

  OnBoard will be used by dental providers to submit Form HP-1.0 requests for arbitration and to request prior authorization for medications, durable medical equipment, non-MTG procedure(s) costing more than $1000, or under or equal to $1000. Learn more about OnBoard.

  Dental providers (along with other health care providers) are required to register for OnBoard via the Board’s Medical Portal.

• How do dental providers submit a Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0) via OnBoard?

  Dental providers (along with other health care providers) are required to register for OnBoard via the Board’s Medical Portal in order to submit Form HP-1.0 requests and/or requests for prior authorization.

• Can I refuse to treat a workers’ compensation patient for dental services?

  Yes, you can refuse to treat a workers’ compensation patient for dental services.

• Do I need to be authorized by the Board to provide dental treatment to workers’ compensation patients?

  No. Workers' Compensation Law does not require dental providers to be authorized by the Board. However, the dental provider must have a valid NYS dental license.

• Do I need to be specialized in order provide treatment to workers’ compensation patients?

  No, any dental provider with any type of dental specialization can treat workers’ compensation patients. The dental provider must have a valid NYS dental license.

• I have a patient who is seeking dental treatment as a result of a motor vehicle accident, do I bill the No‐Fault insurer or the workers’ compensation insurer?

  The dental provider should ask the patient at the first visit if their injuries sustained in a motor vehicle accident occurred while working.

  1. If the patient was working at the time of the accident, it should be treated as a workers' compensation claim.
  2. If the patient was not working at the time of the accident, the no‐fault insurer should be billed. No‐fault rules and regulations can be found at the NYS Department of Financial Services. No‐fault cases are subject to different policy interpretations.

• The workers’ compensation dental fee for my patient's treatment is less than my usual fees. Can I charge the patient the balance between my fee and the workers’ compensation dental fee?

  No, if you accept a workers' compensation patient, you must charge the fees as indicated in the Dental Fee Schedule. You may not accept a fee from a patient for services relating to an on-the-job injury.

• Is the Dental Fee Schedule the same as the No‐Fault dental fee schedule?

  Yes. The NYS Department of Financial Services has adopted the Dental Fee Schedule as its fees for all dental treatment provided to victims of motor vehicle accidents through its No‐Fault program. No‐fault cases are subject to different policy interpretations.

• Do I need to request for prior authorization to the workers’ compensation insurer for dental treatment?

  In accordance with section 13‐a(5) of the Workers' Compensation Law, if the cost of the procedure(s) will exceed $1,000 (according to the dental fee schedule) the dental provider is required to request prior authorization.

  Dental providers are required to register for the Medical Portal and submit a request for prior authorization using OnBoard.

  See all PARs submitted by dental providers.

• Can I require workers’ compensation patients to pay up front for dental work before the work is performed, or bill a workers’ compensation patient for services rendered?

  No. The Workers' Compensation Law does not permit a dental provider to collect from, or bill, a workers’ compensation patient for services rendered, unless a decision is issued by the Workers' Compensation Board indicating the patient 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.

• In addition to the treatment due to the patient's accident at work, the patient also needs full mouth periodontal treatment and additional root canal and restorative treatment. Do I submit a claim for all the necessary dental treatment to the workers’ compensation insurer?

  No. The workers’ compensation insurer is liable only for reimbursement for treatment necessitated by the work-related accident.

• How would I charge for procedures not listed on the dental fee schedule?

  Not all dental codes are listed on the Dental Fee Schedule. Reimbursement for unlisted codes may not be payable and can be subject to the prerogative of the insurer. Where possible, the provider should use similar listed codes found on the Dental Fee Schedule and bill accordingly.

  If there are no similar listed dental codes, CDT code 09999 "Unlisted Adjunctive Procedure By Report" could be utilized, where the provider should establish a fee consistent relative to the other fees listed in the dental fee schedule. All bills submitted using CDT code D9999 should be accompanied by a report providing the reasons why such procedures are necessary.

• How will I be reimbursed for procedures included under “CPT” but not “CDT” codes?

  CPT Procedures would be billed out according to the prevailing workers’ compensation medical fee schedule for the region in which the services are performed.

• What type of workers’ compensation form should I use to bill for dental treatment?

  There are no relevant workers’ compensation forms for billing purposes. The dental provider can use any usual and customary dental billing forms. All relevant treatment plans should be attached with the dental billing forms.

• How do I request prior authorization for treatment?

  Dental providers may use OnBoard to submit prior authorization requests for treatment. Prior authorization is required for Non-MTG treatments over $1,000 and optional for Non-MTG treatment costing less than or equal to $1,000. In addition, dental providers may use OnBoard to request dental-related DME and medications, and to submit Form HP-1.0.

• Where should I send the dental billing forms?

  All relevant billing forms and treatment notes should be sent to the workers' compensation insurer. Copies of bills and treatment plans should also be:

  • Mailed to: NYS Workers' Compensation Board, PO Box 5205 Binghamton, NY 13902-5205, OR
  • Email: wcbclaimsfiling@wcb.ny.gov, OR
  • Web Upload

• I do not know the patient’s workers’ compensation insurer. How can I get this information?

  1. Contact the patient or patient’s legal representative for this information.
  2. Contact the Workers’ Compensation Board District Office and speak to a claims examiner.

• Can an insurer deny a workers’ compensation dental claim?

  1. An insurer can controvert a claim, claiming they are not liable for lost wage payments or medical expenses. OR,
  2. The insurer can also dispute the necessity for dental treatment or that the injuries were not related to the patient's employment.

  In both cases, a Workers' Compensation Law Judge will decide the dispute. In the event a dental provider renders dental treatment during the time the patient's workers' compensation case is controverted or disputed, the dental provider is entitled to an additional 25% reimbursement above the fees listed in the dental fee schedule.

• How long must I wait for payment to be made by my patient's workers’ compensation insurer?

  Claims submitted by a dental provider to the insurer shall be paid within forty‐five calendar days of receipt of the claim. If the bill is disputed, insurer must provide a response and can request additional information. The insurer shall have thirty days to pay the claim or provide written notice to the Board, patient, and dental provider explaining why the claim is not being paid. Where the insurer has failed to pay a claim or make reasonable request for additional information within forty‐five calendar days, the insurer is deemed to have waived any objection to liability for the claim and shall pay the claim.

• The insurer did not respond to within the established time limits, OR, did not pay my dental bill in full. What can I do?

  Request for Decision on Unpaid Bills (Form HP-1.0) is used by a health care provider to ask the Board to make a determination whether a claim administrator should pay a medical bill, which they previously declined to pay in full, or in part, for services rendered to a patient who has a workers' compensation case. Form HP-1.0 should be submitted, along with any necessary attachments, such as copies of medical bills, through OnBoard.

  Note: The HP-1.0 form is submitted through OnBoard but the rest of the process remains the same.

Payer FAQs

• The dental provider submitted a bill with codes that are not listed on the Dental Fee Schedule.

  Not all dental codes are listed on the Dental Fee Schedule. Reimbursement for unlisted codes may not be payable and can be subject to the prerogative of the insurer. Where possible, the provider should use similar listed codes found on the Dental Fee Schedule and bill accordingly.

  If there are no similar listed dental codes, the provider should use CDT code 09999 "Unlisted Adjunctive Procedure By Report", where the provider should establish a fee consistent in relativity with the other fees listed in the dental fee schedule. All bills submitted using CDT code D9999 should be accompanied by a report providing the reasons why such procedures are necessary.

• What type of workers’ compensation form should the dental provider use to bill for treatment?

  There are no relevant workers’ compensation forms for billing purposes. The dental provider can use any usual and customary dental billing forms. All relevant treatment plans should also be attached with the dental billing forms.

• I would like to object to the dental bill. What should I do?

  File 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) (C-8.4), as appropriate.