Workers' Compensation - News from the NIC

The NYSCA Insurance Committee (The NIC) continues to receive numerous calls and emails from our members seeking assistance implementing the new workers' compensation requirements. Our webinars and Lunch and Learn presentations have been well attended. This article will be limited to workers' compensation cases, and offers some pearls which you may find beneficial. The new MVP program (effective 1/1/23) has been addressed in a separate article.

Workers' Compensation

July 1 began the mandatory requirement to submit claims on a CMS-1500 form (electronic or paper) together with your clinical documentation in the required format. 


  • The CMS-1500 with necessary clinical documentation replaces the C4 and C4.2 forms.  
  • To meet the needs of the workers' compensation system, additional fields are required on a CMS-1500 claim form as compared to your commercial claims.  The NIC continues to work with a few EHR and clearinghouse vendors. 
    • Please ensure your EHR Software has been updated to meet the CMS-1500 requirements. 
      For instance, if you are utilizing Eclipse Practice Management Software you must have the most recent version (August 1, 2022) for the workers' compensation CMS-1500 claim forms to print correctly.  There may be some residual field issues; however, we have been advised by Eclipse that these should not result in a delay or denial of your claim. 
  • The Workers' Compensation Board (WCB) has provided a Medical Narrative Report Template to assist with your submission.  Although this Template is not required, the 3 elements of Work Status, Causal Relationship and Temporary Impairment Rating MUST be easily identified.  According to the WCB:
    • “A medical narrative report may be found legally defective if these elements are missing. Medical providers must also include examination findings within their narrative, including the history of the injury/illness, objective findings based on the clinical evaluation, the patient’s plan of care and the diagnosis(es)/assessment of the patient.”
  • Variance Prior Authorization Requests (Variance PAR) must be submitted electronically through the Workers' Compensation Board Medical Portal. 
  • The optional Confirmatory PAR must also be submitted via the Medical Portal.
  • The HP1 Form must be submitted via the Medical Portal.
    • NYSCA members have reported that the HP-1 online process is simple and results in much faster turnaround time that the previous paper process.  We are looking for an update from the WCB as to the status of the previously submitted paper claims.


Is the process working?  Are the carriers compliant?  Is the WCB responsive? 

Please share your successes and challenges so we might share them with others.  The NIC is planning another Lunch and Learn in the next several weeks to offer assistance (notice to follow).  It will also serve as a venue to share your experiences so we can better assist our profession.

A few additional pearls

  • If your workers' compensation claim has been reduced below the Official Workers' Compensation Medical Fee Schedule, you may find it beneficial to file an HP-1.  In some instances, the carrier is utilizing an old fee schedule.  In others, reimbursement is reduced due to a contract you previously signed with a third party (e.g., Multiplan) which has been expanded to include workers' compensation cases.  If there is no agreement on file between the third party and the workers' compensation carrier (or if one is not produced after you file your HP-1), the case will typically be ruled in your favor. 
  • Utilize the 3 required elements from the Medical Narrative Report Template at the top of your initial narrative report and subsequent narrative report to ensure you have addressed these issues, making it obvious to the carrier and WCB.
  • If you submitted your CMS-1500 forms and clinical documentation on paper to the carrier, remember you are required to send the same information to the WCB and the patient (or their duly appointment representative).  Please ensure you are utilizing the correct mailing and email address for the WCB.  The links are listed immediately below.  Note that the WCB no longer publishes the fax number for claim submission.  The NYSCA has always recommended sending your information with proof of submission.
  • Confirmatory PARS are voluntary.  The WCB has recently posted a notice that carriers may deny a PAR that is submitted after care has been rendered.  This does not appear to be possible, as clinical documentation is necessary to complete the PAR.  The NIC is reaching out to the WCB to discuss further.
  • Make sure you are compliant with the submission timeframes.  The WCB has posted the following timeframes:
    • Initial CMS-1500 (formerly the C-4, OT/PT-4 or the PS-4): within 48 hours of first treatment;
    • Subsequent CMS-1500 (formerly the C-4.2, OT/PT-4 or the PS-4): 15 days after first treatment, and thereafter for continuing treatment: after each follow-up visit scheduled when medically necessary but not more than 90 days apart.
  • Remember: the primary method to evaluate and report that your patient is responding favorably to care is via objective measures (quantified) of functional improvement. A selection of Outcome Assessment Tools are available for download in the members-only section of the NYSCA website, linked under Education >> New Practitioners >> Outcome Assessment Tools.

Insurance Committee Lunch & Learn

Join members of the NYSCA Insurance Committee on Monday, September 12, 2022 for a lunch and learn at 1:30pm ET.  This meeting is open to NYSCA members at no charge. A number of vital topics will be addressed, including recent Workers' Compensation updates and major medical insurance updates. We will also be discussing upcoming NYSCA initiatives, including a new member benefit - Financial Wellness Program webinars. We will also take time to consider questions, issues, or concerns from attendees that have been submitted prior to the meeting.

Please register to join us for this important meeting!

As always, thank you for your continued dedication.

Together We Are NYSCA!

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