Providers
With the CMS-1500 submission mandate, as of August 1, 2025, the NYS Workers' Compensation Board is requiring health care providers, regardless of office size or patient population, to submit the CMS-1500 universal medical billing form electronically through a Board-approved electronic submission partner.
To make the process as easy as possible, as of July 28, 2025, the Board removed the requirement for providers to log into the Medical Portal and accept the "Agreement for electronic submission of CMS-1500" before working with a submission partner.
The Board will no longer act on, or enforce payment of, paper CMS-1500 forms and workers' compensation payers can deny them, which means the submitting provider will not be paid. To ensure uninterrupted payment for services, the Board urges all providers to transition to electronic submission now.
Payers
The electronic process, prescribed by the Chair, requires payers to partner with at least one Board-approved electronic submission partner to transmit and accept health care provider medical bills via Electronic Data Exchange (EDI), or another format agreed upon with the electronic submission partner.
Payers must designate with the Board the electronic submission partner(s) from whom they accept medical bills. The payers' Medical Portal Online Administrators must keep electronic submission partner information accurate and update the online administrator application with any changes within three (3) business days. Detailed instructions on updating electronic submission partner designations can be found on the Designating an Electronic Submission Partner page.
A list of approved electronic submission partners for the CMS-1500 is posted on the CMS-1500 Electronic Forms Submission section of the Board's website and is updated after each entity successfully completes testing and executes an Electronic Submission Partner Agreement with the Board.
Please contact the WCB Online Services Technical Support Unit if you have technical questions regarding adding an electronic submission partner.
Workers' compensation payers will electronically transmit Explanation of Benefits/Explanation of Reviews (EOBs/EORs) to their electronic submission partners upon adjudication of the associated electronic CMS-1500 medical bills. The electronic EOBs/EORs may be in the X12 835 EDI standard or any other mutually agreed-upon data file format. Such EOB/EOR data will be forwarded from the electronic submission partner back to the provider.
Payers are required to use specific Claims Adjustment Reason Codes (CARC) on their provider EOBs/EORs when objecting to payment of a medical bill whether the bills are received through an electronic submission partner or on paper. Please note: For CMS-1500 submissions other than electronically, the Board has identified CARC 16/RARC N34 is to be used. Listing of CARCs and additional guidance: Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs). The provider may file Health Provider's Request for Decision on Unpaid Medical Billing (Form HP-1.0) based on receipt of the EOB/EOR with required CARC codes. The new Notice of Objection to a Payment of a Bill for Treatment Provided (C-8.1B) and 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) forms, as well as the payers' use of specific CARCs implemented July 1, 2022, which became mandatory on September 19, 2022. Previous versions are no longer accepted, and no action will be taken by the Board should a payer continue to use them. Do not submit a Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B) when objecting to paper bills received after August 1, 2025. Rather, issue the provider an Explanation of Benefits / Explanation of Reimbursement that references CARC 16/RARC N34 codes, to indicate the provider's bill was not submitted electronically.
Additionally, payers are required to identify all legal and valuation objections to payment of the medical bill at the same time and file such objections by paper or electronically using Forms C-8.1B or C-8.4 within 45 calendar days of acknowledgement of receipt of the medical bill. See Subject Number 046-1465 Adoption of Amendment to 12 NYCRR 325-1.25 (Medical Billing Disputes).
Electronic submission partners
All electronic submission partners must execute a Test Agreement for Business Partners Submitting Medical Reports in XML Format, successfully complete CMS-1500 XML testing and execute a new Electronic Submission Partner's Agreement for Electronic Submission of CMS-1500 Forms and Medical Narrative Reports on Behalf of Health Care Provider with the Board. Clearinghouses interested in becoming an electronic submission partner will need to register first with the Board.
The Board will accept the CMS-1500 form, medical narrative and/or attachments, and acknowledgment receipts from payers, using the Board's specific electronic form submission process. Electronic submission partners may also be required to submit reporting metrics to the Board documenting the efficiency of form submission to the payer. The electronic submission partners will be required to submit CMS-1500 and narrative reports to the Board within seven business days of receipt from the provider. When a CMS-1500 and narrative report are not accepted by the payer within three business days, the electronic submission partner will be required to advise the provider and seek direction as to whether to continue electronic submission attempts or submit the CMS-1500 and narrative report in paper format. The reporting requirements of the Workers' Compensation Law and its regulations, specifically 12 NYCRR §325-1.3, remain unchanged. Providers (and electronic submission partners on behalf of providers) are required to remain compliant with these reporting requirements.