Overview
The Expanded Provider Law (EPL) went into effect in New York State as of January 1, 2020. This means that licensed clinical social workers, acupuncturists, nurse practitioners, physician assistants, occupational therapists and physical therapists may now become Board-authorized to treat injured workers, and bill in their own name.
To help payers comply with the new law, and to also prevent any unnecessary billing disputes and/or requests for arbitration, the Board has compiled some helpful information.
Medical and Billing Form Updates
As the Board works to integrate newly authorized providers into the New York State workers’ compensation system, there are some important clarifications regarding the use of certain medical and billing forms.
Important note related to bills from nurse practitioners and physician assistants: As the Board makes the transition to the CMS-1500 universal billing form, nurse practitioners and physician assistants who have been approved for XML submission of the EC4-Narr in the interim have been instructed to use their NPI number only, while CMS-1500 XML submission also requires the provider’s authorization number and rating code. Payers should not deny any EC4-NARRs that do not have an authorization number or rating code during this transition period.
How Can You Check Authorization Status?
The Board has an online search of all health care providers and independent medical examiners who are authorized with the Workers’ Compensation Board. For a full list, use the Find All tab and view/download results in Excel. You can also stay informed of changes to the authorized provider list by subscribing for WCB updates.
Which Medical Fee Schedules do the New Provider Types Use?
The following table details the Medical Fee Schedule each new provider type must use. It is important to note that while there some revisions to the NYS WCB Medical Fee Schedule effective 01/01/2020, there were no CPT coding changes made. With the exception of the NYS Workers’ Compensation Acupuncture and Physical & Occupational Therapy Fee Schedule which must be purchased from Optum360, all other revisions to the fee schedule are available as free downloads from Optum360.
Since the new providers will be submitting their own billing, modifiers AJ, NP or PA are no longer billed or applied to the fees. See the Ground Rules for each fee schedule for full details.
| Provider Type | Medical Fee Schedule | Things to Know: |
|---|---|---|
| Acupuncturist | NYS Workers’ Compensation Acupuncture and Physical & Occupational Therapy Fee Schedule | This fee schedule must be purchased from Optum360 at https://www.optum360coding.com/reference-products/workers-compensation or by calling 1 (800) 464-3649. |
| Licensed Clinical Social Worker | NYS Workers’ Compensation Behavioral Health Fee Schedule | You can download updates to the NYS Workers’ Compensation Behavioral Health Fee Schedule from Optum360. |
| Nurse Practitioner | NYS Workers’ Compensation Medical Fee Schedule | You can download updates to the NYS Workers’ Compensation Medical Fee Schedule from Optum360. |
| Physician Assistant | New York Workers’ Compensation Medical Fee Schedule | You can download updates to the NYS Workers’ Compensation Medical Fee Schedule from Optum360. |
| Occupational Therapist | NYS Workers’ Compensation Acupuncture and Physical & Occupational Therapy Fee Schedule | This fee schedule must be purchased from Optum360 at https://www.optum360coding.com/reference-products/workers-compensation or by calling 1 (800) 464-3649. |
| Physical Therapist | NYS Workers’ Compensation Acupuncture and Physical & Occupational Therapy Fee Schedule | This fee schedule must be purchased from Optum360 at https://www.optum360coding.com/reference-products/workers-compensation or by calling 1 (800) 464-3649. |
What If You’ve Denied Bills In Error?
All payers should identify and fix any claims that were not processed appropriately in accordance with the EPL. For these instances, it is recommended you contact the treating provider to inform them the bill will be reprocessed so they do not initiate the medical billing dispute Request for Decision on Unpaid Medical Bills (Form HP-1) process, or if they have already done so, they may submit a Notice to Chair: Health Provider’s and Insurer’s Withdrawal of Request for Arbitration (Form HP-4) to prevent it from moving any further. After verifying that the provider is WCB authorized, any Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B) submitted raising the legal issue that the provider is not authorized should be withdrawn.
Where Can You Go For More Information?
- View a recorded presentation specifically for payers: Billing Updates for Payers: CMS-1500 and Expanded Provider Initiatives
- For questions about medical billing, contact the Board’s Medical Directors Office at MDO@wcb.ny.gov.
- To get email notification on changes to the authorized provider list and other Board updates, subscribe for WCB notifications.