Payers are a critical partner in helping the injured workers of New York State (NYS) get better and back to their lives! Here are important resources and requirements for payers to be aware of regarding the workers' compensation system.

Getting started

Becoming a NYS Workers' Compensation Board (Board) authorized payer

Obtaining a W Number

Registered insurance carriers, as well as employers who have been approved to self-insure for workers' compensation benefits in New York State, are assigned a 7-character identification number beginning with a W (known as a "W Number" or "Insurer Code (ID) Number") by the Board. This number is used to identify workers' compensation coverage in the Board's insurance coverage system and to gain access to electronic case files for workers' compensation claims (eCase) and filing of required documentation.

To obtain a W Number, email wcb.sm.WCPOC.Support with your request. You will typically receive a response in three to five business days.

The Board requires all insurance carriers to submit Proof of Coverage (POC) electronically. As a result of that mandate the Board has recognized the carriers' need for a tool to access their policy and coverage data to address compliance issues for their customers.

This online service provides carriers with a view of their policy and coverage data on record at the Board. This tool should assist carriers in managing both business and jurisdictional issues related to New York filings.

Using this application, payers can:

• Verify status of POC submitted to the Board for a workers' compensation policy term, as well as the employer/location
• Confirm POC filings for worker's compensation policies and employer locations
• Verify the status at the Board of disability benefits coverage
• Respond to Board compliance notices for their clients
• View and print transaction history for electronic POC filings
• Print reports to manage POC and claims issues

Read more on the Insurance Compliance Inquiry Overview page.

eClaims

eClaims is claim information reported by Claim Administrators through the First Report of Injury (FROI) and Subsequent Report of Injury (SROI) using the International Association of Accident Boards and Commissions (IAIABC) Electronic Data Interchange (EDI) standard.

Becoming a trading partner

Trading partner registration is required of all parties sending claims data to the NYS Workers' Compensation Board (Board) in the mandated IAIABC Claims Release 3.1 format. The Board has developed an online registration application to support this process. This will apply to both secure file transfer protocol (SFTP) and web submissions. Registration will require one or two steps to complete.

Once approved, payers can register for various online services, including:

Additional resources:

• Requirements tables – tables and charts that provide information to trading partners to assist them in submitting the First Report of Injury (FROI) and Subsequent Report of Injury (SROI) transactions.
• eClaims Overview page – provides an overview of eClaims, including an implementation guide and FAQs.

Registering for the Medical Portal

Accessing OnBoard

Registering for eCase

Registering for the Monitoring / Payer Compliance program

The Board monitors payers for timely filings of certain payments and forms and imposes penalties when the stated timelines are not met. Carriers and self-insured employers must be registered for Payer Compliance and have eClaims inquiry access to view the penalties associated with their untimely filings for the categories below. To register for Payer Compliance access, please email Monitorregistration@wcb.ny.gov

• First Report of Injury (FROI)
• Subsequent Report of Injury (SROI) showing initial payment
• Initial payment
• Installment payment
• Controversy under 25.3e and 25.2a
• Suspension under 25.3e and 25.1d

Visit the Monitoring and Compliance Presentations page to learn more about timelines and monitoring.

Please note: Third-party administrators do not need to register for Payer Compliance as penalties are against the carrier/self-insured employer and access is obtained through your Trading Partner Agreement.

Visit the Inquiry Overview page to view both accepted and rejected claim transactions submitted to the Board, view payer compliance reports, and request review of any penalties associated with these reports.

Administering claims and reporting

First Report of Injury / Subsequent Report of Injury

Let the NYS Workers' Compensation Board (Board) know about a claim through the First Report of Injury (FROI) / Subsequent Report of Injury (SROI). This can be done through SFTP or through web data entry.

Requirement tables

An integral part of the Board's implementation of the IAIABC EDI Release 3.1 standard for electronic FROI/SROI submissions is the requirement tables which define all of New York's submission events and data elements associated with FROI/SROI submissions.

Requesting action by the Board

The insurance carrier or employer may file a Request for Further Action (Form RFA-2) in a workers' compensation case when it seeks Board action regarding an issue related to the case that it has been unable to resolve with the claimant or their representative. A copy of the form and any attachments must also be sent to the claimant and their attorney or legal representative, if they have one.

Some issues may be resolved informally, without a hearing, while more complex disputes may require a formal hearing before a Workers' Compensation Law judge. Parties may also choose to enter into an agreement, such as a stipulation or a Section 32 Waiver Agreement, to resolve issues. Visit the Issues Resolution page for more information.

Special Funds Group

After a request for reimbursement [Insurer's Request for Reimbursement of Indemnity Payments Under WCL Section 14(6) or Section 15(8) (Form C-251) or Insurer's Request for Reimbursement of Medical Payments Under WCL Section 15(8) (Form C-251.1), as appropriate] is filed, insurers will receive a confirmation of receipt or an email from the Special Funds Group. The confirmation will be issued if the reimbursement request is complete and contains sufficient information and will include a reference number to be used for any follow up or amendment to a submission.

Read more about the Special Funds Group, including the review process.

Prior authorization of medical treatment

A prior authorization request (PAR) is a request by an injured worker's health care provider to obtain prior approval from the payer (e.g., insurance carrier) to cover the costs associated with a specific treatment under workers' compensation insurance. There are several categories of treatment that require prior authorization. In certain situations, PARs can be escalated for review by the Board's Medical Director's Office (MDO).

New York Medical Treatment Guidelines

The Board's New York Medical Treatment Guidelines (MTGs) are the standard of care for treating individuals with work-related injuries and illnesses in New York State and are based on the best available medical evidence and the consensus of experienced medical professionals.

You can view the current MTGs as well as FAQs and other MTG resources.

Paying/denying bills

Payers are required to pay health care providers based on the Official New York Workers' Compensation Medical Fee Schedule, which can be purchased from OptumInsight 360. Payers are required to pay durable medical equipment suppliers and providers for equipment based on the Official New York Workers' Compensation Durable Medical Equipment (DME) Fee Schedule (Effective 4/4/2022).

These bills must be paid within 45 days of receiving the bill to be considered timely. If a health care provider does not receive timely payment, or disagrees with the reimbursement amount, the health care provider may submit a Request for Review of Unpaid Bills (Form HP-1.0) through the Board's business information system, OnBoard.

Payers should submit potential legal and valuation objections via the Notice of Treatment Issue/Disputed Bill (Form C-8.1B) 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) forms. Additionally, payers are 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 payer 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. Note: The new forms have been updated to include the associated CARC and RARC codes.

If the health care provider submission of a Form HP-1.0 is timely and results in an administrative award issued by the Board, parties of interest are given thirty (30) days to submit a written objection to the proposed award. All supporting documentation is reviewed by the Board and a determination/reconsideration shall be sent to all parties of interest.

If the payer filed a timely Form C-8.4 and the provider submission is found in compliance, a Notice of Arbitration Hearing will be issued. Parties of interest are given thirty (30) days to submit supporting documentation.

Read more about the arbitration process in the Medical Billing Disputes section of the Board's website.

Resources

Webpages

Insurers, Self-Insured Employers, Third-Party Administrators, Workers' Compensation Resources for Claim Administrators, eClaims, Monitoring and Compliance, Insurer ID (W Number)

What Payers Need to Know webinars

Join this webinar to learn how we're making it easier for payers to review and process workers' compensation claims. Visit the Upcoming Webinars page for the most recent webinar schedule.

eClaims news

Visit the eClaims News Archive for the latest on eClaims.

eClaims webinars

The NYS Workers' Compensation Board (Board) regularly hosts eClaims webinars to share important updates with trading partners. Registered business and administrator contacts in a trading partner's profile will receive an email regarding new webinars. You can view the recordings or slides of past sessions on the eClaims Presentations page and register for upcoming webinars by visiting the Upcoming Webinars page.

WCB Notifications

To stay informed on important updates from the Board, sign up to receive WCB notifications . This will send Board news straight to your email inbox. You can choose to subscribe for alerts on the topics you care most about.

Payer updates

Update to Payer Compliance penalty review process

To better assist payers in developing proper compliance procedures, the Board is clarifying the process when a payer requests review of a penalty proposed by Payer Compliance.

Read more in notification dated June 21, 2024 .

Board targets fall 2024 return of in-person hearings

The Board is pleased to announce that we are targeting a fall 2024 opening for multiple hearing locations/customer service centers across the state.

Read more in a notification dated June 14, 2024 .

Fall conference

The Board is hosting a conference at the Empire State Plaza in Albany, NY on October 18, 2024. This full-day program is targeted to all who have a professional interest in the New York State workers' compensation system. Multiple CLEs and CMEs will be available. Sign up for email/text notifications to receive complete details and registration information in the coming months.

Read more in a notification dated May 1, 2024 .

Additional criteria for Section 32 waiver agreements reviewed without a hearing

Effective July 1, 2024, the Board will utilize a desk review process, as opposed to a formal hearing, to review Section 32 waiver agreements involving claimants who are represented by counsel, in which the gross settlement amount is $10,000.00 or less.

Read more in a Subject Number 046-1683.

New maximum weekly benefit rate

The maximum weekly benefit rate will be $1,171.46 for compensable lost time for workers' compensation claims with dates of injury during the period from July 1, 2024, through June 30, 2025.

Read more in Subject Number 046-1678.

Reminders

Telehealth is now a permanent option in the workers' compensation system. Read more in Subject Number 046-1613, and see our new telehealth webpage for additional information.

The What Payers Need to Know section of the Board's website walks payers through getting started in the workers' compensation system, becoming a trading partner, administering claims, and more.

Use of the CMS-1500 form is mandatory. Visit CMS-1500 initiative for more details and send your questions to CMS-1500@wcb.ny.gov.

Visit the Board's website for OnBoard training guides, webinar recordings, and other resources.

Efficiency Enhancements is a new communication with tips and best practices on using Board systems, processes, and forms in the most efficient, effective manner. Sign up to receive these, and other updates, straight to your inbox.

The Board is hosting free COVID-19 & workers' comp webinars. The Board has been hosting a series of webinars to aid workers with long COVID workers' compensation claims. Additional dates will be added soon!

The latest versions of several Paid Family Leave presentations are available, including family care, foster care/adoption, military leave, and bonding. Visit the Paid Family Leave website for more information.

Stay Informed!

Check out the Board's Payers Recorded Webinars and Guides web page for past webinars.

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Archived Updates

Contact

Visit the Contact Us page for a complete list of Board office contact information.