With the CMS-1500 form mandatory in New York State for all workers’ comp bills, providers may need guidance on how to complete the CMS-1500 correctly to ensure payment. While many of the CMS-1500’s fields are straightforward and intuitive (such as the patient’s name and diagnosis codes) some fields require closer study.

For example, Field 19 of the CMS-1500 for “Additional Claims Information” requires a provider to furnish several pieces of information in a strictly specified format.

When submitting the CMS 1500, Field 19 is designated as “Reserved for local use,” meaning that there is no specific information for this box that applies in every state or billing situation. Moreover, for New York State, there are slightly different requirements for Field 19 depending on whether the provider bills electronically or on paper.

Below is a complete guide to Field 19 of the CMS-1500 for New York State workers’ comp billing.

Field 19: Required Information for ELECTRONIC CMS-1500 Bills

First, the good news: for providers who choose to bill electronically, the provider’s XML Submission Partner supplies software and support designed to help ensure correct completion of the CMS-1500 — including Field 19.

When submitting a New York workers’ comp e-bill, the WCB instructs that box 19 includes a string of mandated information. For example, a compliant entry for Field 19 looks like the following (note that the three blank spaces between each grouping of information is mandatory):

REFX5123456-7   G2COS   PWK06EAC000000123456   NTEADD20220701

Each of the groupings of letters and numbers above represents certain required information for a compliant electronic CMS-1500, as broken down below:

• REF - required identifier
• X5 - required qualifier
• 123456-7 - Board authorized Rendering Provider WCB Auth Number
• G2 - required qualifier
• COS - Board authorized Rendering Provider WCB Rating Code
• PWK - required qualifier
• 06 - Report Type Code for Initial Report
• E - required code for electronic
• AC000000123456 - Unique Attachment Control Number
• NTEADD - required prefix
• 20220701 - carrier receipt/acknowledgement date

As to the specifics behind each of the groupings above, the WCB offers further Field 19 instructions in its CMS-1500 Field Table Matrix for XML Submission.

The XML Submission Partner’s software translates the above Field 19 information into XML data, as shown below in the example generated by daisyBill software.

From there, the software populates Field 19 of the electronic CMS-1500 with the correct information.

If e-billing seems complex, it is. But rest assured — the results (faster, more accurate payment and a serious reduction in administrative expenses) are well worth the learning curve. More importantly, the right XML Submission Partner will have the expertise and experience to make e-billing smooth, efficient, and understandable.

Field 19: Required Information for PAPER CMS-1500 Bills

When submitting a CMS-1500 on paper, Field 19 has similar — but distinct — requirements. An example of a correct Field 19 entry for a paper CMS-1500 looks as follows:

REFX5123456-7   G2COS   PWK06BM

Again, each of the groupings of letters and numbers above represents certain required information for a compliant paper CMS-1500, as broken down below:

• REF - required identifier
• X5 - required qualifier
• 123456-7 - Board authorized Rendering Provider WCB Auth Number
• G2 - required qualifier
• COS - Board authorized Rendering Provider WCB Rating Code
• PWK - required qualifier
• 06 - Report Type Code for Initial Report
• BM - “By Mail” Transmission Type Code

The WCB also provides a CMS-1500 Field Table Matrix for Paper.

New York State workers’ comp providers, we are here for you. daisyBill’s mission is to help injured workers and providers by making e-billing work as smoothly as possible for all concerned. Reach out to us, and we’ll be happy to offer our expertise with regard to any of your questions or concerns.

 Need a hand making the transition to workers’ comp e-billing? daisyBill makes it easy. Reach out to see how we can help your practice.

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