­News from the NIC - May 2022 - Workers’ Comp Updates

Welcome to Spring!  The NYSCA Insurance Committee (The NIC) would like to provide this summary update of recent insurance-related issues which may impact your practice.  This edition is dedicated to Workers’ Compensation, and in particular the continuing rollout of the NYS Workers’ Compensation OnBoard Initiative and submission requirements. 

We will be reporting on commercial carriers and third party administrators next week. 

Telemedicine Services extended by the WCB

The NYS WCB continues to extend the ability to provide our patients with telemedicine services for social distancing purposes due to Covid-19.  The requirements and parameters of billing for telemedicine services have not changed, and can be reviewed at the following web page:

325-1.8 Emergency medical aid and telemedicine

Phase I OnBoard Limited Release (OBLR)

HP-1 forms must be completed online via the Provider Portal

The HP-1 form, utilized to request decisions on unpaid medical bills, is no longer accepted on paper.  The WCB has done an excellent job in streamlining the online submission process.  The timeframe to submit an HP-1 for your unpaid workers’ compensation claim has not changed – only the filing process. This is a simple process to protect your reimbursement for services rendered consistent with the Medical Treatment Guidelines.  Do not miss out on payment due to a technicality.


The Workers’ Compensation Durable Medical Equipment Fee Schedule is finally live.

Rather than billing per invoice as you have in the past, the official NY WC DME Fee Schedule includes applicable HCPCS codes, associated reimbursement values, and whether each specific DME requires Prior Authorization (PAR). DME not listed in the DME Fee Schedule requires prior authorization.  

The Medical Treatment Guidelines (MTGs) supersede the DME schedule - Even if the DME is listed on the Fee Schedule without a prior authorization requirement, the DME must also be recommended by the applicable Medical Treatment Guideline for coverage. 

Always select the most appropriate CPT/HCPCS codes that describes the service rendered (in this case the DME). The new Fee Schedule and related processes should facilitate the appropriate use and reimbursement of Durable Medical Equipment for injured workers.

The DME Fee Schedule is linked below:

NYS Workers Compensation DME Fee Schedule

The WCB has also assembled a frequently asked question page specific to DME, which is linked below:

DME Fee Schedule Frequently Asked Questions


Prior Authorization and New Medical Treatment Guidelines Effective May 2, 2022

Phase III of OBLR begins Monday, May 2nd, and includes the ability to request prior authorization of treatment and testing services via the Medical Portal.  The current MG-2 will become obsolete and is being replaced by the online Prior Authorization Requests (PAR).  By completing the request on line, the information you enter will automatically determine which type of PAR needs to be completed.  This takes the guesswork as to whether a PAR is required, and if so, what type.  This should finally eliminate erroneous carrier Variance request for an exacerbation where treatment was rendered consistent with the Medical Treatment Guidelines. 

In addition, authorized treating providers can request confirmation from the carrier that the procedure(s) or tests is consistent with the applicable Medical Treatment Guideline, reducing the chance of your claim being denied.  Previously carriers had the ability to ‘opt out’ of requests for prior authorization submitted on paper via an MG-1.  If you request an MTG Confirming PAR, the carrier can no longer opt out – carrier response is mandatory.  Another win for the authorized treating provider!

Similarly, you may request prior authorization prior to dispensing medically necessary DME consistent with the recommendations of the MTGs and the DME Fee Schedule.  Other types of PARs will be available and are outlined on the OnBoard section of the WCB web portal.

May 2nd also formally adopts the previously discussed updates to the Neck, Mid and Low Back, and Non-Acute Pain Guidelines.  One significant change is the reference numbers for each procedure (such as spinal manipulation and physical medicine services) utilized when submitting a request for Prior Authorization.  Please utilize the updated MTGs to ensure you have completed the PAR correctly. 

Note that the Workers’ Compensation Board has adopted more than a dozen new guidelines for other work-related conditions.  As the NYSCA continues to work to modernize our Scope of Practice, we look forward to the day when we can treat our patients for all conditions consistent with their needs and our education.

Medical Treatment Guidelines

CMS 1500 replaces most C4 forms effective July 1, 2022

Beginning July 1, 2022 the use of the CMS-1500 will be mandatory, and electronic submission by providers through an XML submission partner will be strongly encouraged, although not required.  The initiative will leverage providers' current medical billing software and medical records while promoting a more efficient workers' compensation system.  The Board will replace most of the C4 family of forms, including the C-4 Initial Report and C-4.2 Progress report.  The C4.3 Doctor's Report of MMI/Permanent Partial Impairment remains intact, and can be submitted electronically with your CMS-1500. 

For those of you already utilizing electronic health records and submitting claims electronically, the conversion (which requires the use of a NYS WCB approved XML claim submission partner) is straight forward but does take time.  Many doctors have already made the transition.  After transition, most docs have reported positive feedback both with respect to the process and more rapid payment.  The cost to submit electronically is minimal.  There are only a few approved clearinghouses which are approved by the WCB.  The list can be viewed at the page linked below:

XML Forms Submission - Overview (ny.gov)

Many approved clearinghouses (such as Carisk Intelligent Clearinghouse) incorporate electronic claim and medical record submission for No Fault cases as well.  Carisk also prints and mails claims which are not accepted electronically.  Electronic submission includes tracking, eliminating denials for untimely or ‘lost’ mail.  Another win!

If you are planning to submit a paper CMS-1500, note that additional data requirements must be completed in the appropriate fields in order for your CMS-1500 to be considered complete.  All payers have been required to accept your claims and supportive documentation electronically for nearly 6 months.  We anticipate that some carriers will deny paper CMS-1500s effective 7/1/22.  Given the positive feedback we have received (and experienced) to date, we strongly encourage the use of electronic submission through an approved clearinghouse. 

As a reminder, both electronic and paper submission requires a medical narrative.  To expedite the review and processing, the WCB created a Medical Report Template which can be viewed and downloaded at the page linked below:

Medical Narrative Report Template for CMS-1500 

Remember the basic tenants of reporting, especially Positive Patient Response / quantified functional improvement.  Many docs are incorporating their narrative report onto the template quite successfully.  Some are utilizing templates designed by the EHR.  Others are simply typing a report, saving as a pdf, and submitting with their claim.  If you are not utilizing the WCB Template, be sure to display Work Status, Causal Relationship and Temporary Impairment Percentage prominently (preferably at the beginning of your report to expedite review by all parties).   

Other Form Updates

The Doctor's Report of MMI/Permanent Partial Impairment, C4.3, was recently been updated.  When completing a C4.3, please ensure you are utilizing the most up to date version and submit your completed C4.3 with a CMS-1500 with CPT code 99243.

Emergency Adoption and Proposed Amendments

Please also note that the WCB Chair, Clarissa Rodriguez, has adopted on an emergency basis a proposed amendment to ensure that sacroiliac joint fusion and peripheral nerve stimulation are not performed unnecessarily, and that if medically necessary, that prior authorization is obtained.  As with any proposed amendment, a 60 day public comment period applies after publication.


The best way to keep up is to Stay Informed!  The WCB continues their work to streamline many processes (including Request for Further Action),  and automate that which they can. 

One of the easiest methods to receive updates is to sign up for WCB notification via email or text.  To subscribe for WCB updates utilize the following link:

Email/SMS Updates

For additional OnBoard information, consult the following links:

OnBoard: Limited Release
Frequently Asked Questions for Insurers
OnBoard: Limited Release
What health care providers need to know

For additional information on the required transition to CMS1500 claim forms, consult the following link:

CMS-1500 Initiative Overview

Next week’s News From the NIC will include important commercial insurance updates, and we will once again request your assistance in quantifying issues so we may endeavor to resolve them on your behalf. 

In Closing

The NIC would like to thank you for your continued dedication to your patients and our profession. We will continue to provide detailed information via email, webinars, and at your local district meetings. We look forward to continuing our work with you, and advancing our profession to better serve our present and future patients. 

Together, We Are NYSCA!

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