WHAT PAYERS NEED TO KNOW - ARCHIVED UPDATES
April 21, 2025
CMS-1500 electronic mandate approaching! Cost offset available to providers now.
The Board encourages health care providers who are still submitting paper CMS-1500 medical bills to move to electronic submission as soon as possible to take advantage of increased accuracy and more timely payment, among other key benefits.
Impt: Providers can offset the cost of electronic transmission using a designated CPT code. Payers who do not properly reimburse for this code may be subject to penalties from the Board.
Read more in a notification dated April 10, 2025.
DB-PFL proof of coverage penalty update
As a reminder, the New York State Workers' Compensation Law (WCL) §226 authorizes the Board to penalize insurance carriers who fail to file proof of coverage (POC) transactions in a timely manner. The Board will be measuring performance of disability benefits/Paid Family Leave carriers quarterly on the timeliness of Add Policy (new) and Cancelation transactions. Upon implementation (exact date to be announced), carriers that do not meet an 85% performance rate will be penalized for any untimely Add Policy and Cancellation transactions.
See the notification dated April 11, 2025, for important actions payers should take now.
Updates regarding Section 32 waiver agreement forms
The Board has updated its Waiver Agreement – Section 32 WCL (Form C-32) and Section 32 Waiver Agreement: Claimant Release (Form C-32.1) to assist the Board in determining liability for medical bills involving treatment of established sites in cases being settled by a Workers' Compensation Law (WCL) Section 32 waiver agreement, as well as to account for recent process updates. Beginning Monday, July 7, 2025, the Board will no longer accept Form C-32 and C-32.1 with earlier version dates.
Read more in a notification dated April 7, 2025.
Important updates to C-300.5 and C-312.5 forms
Effective immediately, the Board has updated Stipulation (Form C-300.5) and Agreed Upon Findings and Awards for Proposed Conciliation Decision (Form C-312.5) .
Both updated forms now include fields to:
- Provide information on claimant representatives, substitutions, and related fee requests/agreements.
- Denote whether the case has a pending appeal.
Read more in a notification dated April 7, 2025.
Clarification of Subject Number 046-124: Rights and Responsibilities of Parties to a Workers' Compensation Claim When Communicating with Treating Health Care Professionals and Independent Medical Examiners
The Board is aware that some attorneys believe that Subject Number 046-124 precludes interested parties from any communication with a health care professional who has treated or examined an injured worker. To clarify, Subject Number 046-124 was never intended to be interpreted as precluding proper communication with a health care professional who has treated or examined an injured worker. Proper communication can be helpful to obtain clarity and avoid unintended disputes resulting in litigation.
Read more in Subject Number 046-1749.
Proposed Amendments to Sections 440.3, 440.4, and 441.3 and Title 12 of the NYCRR (Network Pharmacies)
The Chair proposes amendments to section 440.3, 440.4, and 441.3 of Title 12 of the NYCRR to provide that a payer must notify the claimant that they may use a non-network pharmacy when the payer maintains (or will maintain) a legal objection that the medication is for treatment of an injury or condition that has not yet been accepted or established by the Board.
The Board is currently assessing public comments received during the public comment period.
Read more in Subject Number 046-1731.
Reminders
Telehealth is now a permanent option in the workers' compensation system. Read more in Subject Number 046-1613.
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 CMS1500@wcb.ny.gov.
Visit the Board's website for OnBoard training guides, webinar recordings, and other resources.
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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.
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