Workers' Compensation Medical Billing State Guides
New York Workers' Compensation Medical Billing Guide
New York operates a statutory Workers' Compensation framework administered by the New York State Workers' Compensation Board (WCB) under Chapter 67 of the Consolidated Laws. Medical billing is strictly benchmarked to the Official New York State Workers' Compensation Medical Fee Schedule (12 NYCRR Part 329). Unpaid medical bill disputes are resolved administratively via Form HP-1 and Form HP-1J arbitration.
Plain-language overview
Statutory Administrative System (New York Workers' Compensation Law)
New York operates a statutory Workers' Compensation framework administered by the New York State Workers' Compensation Board (WCB) under Chapter 67 of the Consolidated Laws. Medical billing is strictly benchmarked to the Official New York State Workers' Compensation Medical Fee Schedule (12 NYCRR Part 329). Unpaid medical bill disputes are resolved administratively via Form HP-1 and Form HP-1J arbitration.
Medical fee schedule and reimbursement rules
Name
New York State Medical Fee Schedule (12 NYCRR Part 329)
Rules
Reimbursement is calculated using relative value units multiplied by New York region-specific conversion factors (Regions 1 through 4). Variance from the fee schedule is impermissible absent prior WCB pre-authorization (Form MG-2 or C-4 AUTH).
Cpt Basis
HCPCS/CPT codes with proprietary NYS WCB relative value units and regional conversion factors
Billing and appeal procedure
Medical Bill Submission
Healthcare providers must submit medical bills on standard CMS-1500 accompanied by the mandatory WCB Medical Narrative Report within 90 calendar days of treatment.
Carrier Response
Carrier must pay the bill or submit Form C-8.1 (Notice of Objection to Payment of Medical Bills) within 45 calendar days of receipt.
Hp1 Dispute Process
If an objection is purely legal or related to the fee schedule, the provider files Form HP-1 (Healthcare Provider's Request for Decision on Unpaid Medical Bill) requesting an administrative award or arbitration.
Claim and dispute deadlines
Deadlines can depend on the trigger event and may be affected by agency relief notices. Confirm the live rule before filing.
| Event | Timeframe |
|---|---|
| Medical Bill Submission to Carrier | Within 90 calendar days of service (12 NYCRR § 325-1.25) |
| Carrier Form C-8.1 Objection Window | Within 45 calendar days from receipt of bill |
| Provider HP-1 Dispute Filing | Within 90 calendar days from receipt of Form C-8.1 denial |
| WCB Administrative Order of Approval | 30 days from non-response by carrier |
Documentation checklist
- Board-Authorized Healthcare Provider WCB Authorization Number
- Completed CMS-1500 form with mandatory narrative fields
- Contemporary medical progress reports demonstrating causal relationship
- Approved Form MG-2 or C-4 AUTH variance for procedures exceeding MTG guidelines
- Carrier Form C-8.1 objection or proof of carrier non-payment after 45 days
Responsible agencies
- New York State Workers' Compensation Board (WCB)Statewide Workers' Compensation Administration & Medical Fee Schedules
Primary legal and regulatory sources
- New York Workers' Compensation Law Chapter 67, Section 13 (Treatment and Care of Injured Employees)New York State Legislature · 2024
- New York Codes, Rules and Regulations (NYCRR) Title 12, Chapter V (Medical Fee Schedules)New York State Workers' Compensation Board · 2025
This operational reference is educational, is not legal advice, and does not create an attorney-client relationship.
Common questions
- What rules govern workers' compensation medical billing state guides in New York?
- New York operates a statutory Workers' Compensation framework administered by the New York State Workers' Compensation Board (WCB) under Chapter 67 of the Consolidated Laws. Medical billing is strictly benchmarked to the Official New York State Workers' Compensation Medical Fee Schedule (12 NYCRR Part 329). Unpaid medical bill disputes are resolved administratively via Form HP-1 and Form HP-1J arbitration.
- What dispute deadlines should providers track in New York?
- Medical Bill Submission to Carrier: Within 90 calendar days of service (12 NYCRR § 325-1.25); Carrier Form C-8.1 Objection Window: Within 45 calendar days from receipt of bill; Provider HP-1 Dispute Filing: Within 90 calendar days from receipt of Form C-8.1 denial. Verify the trigger date, current agency notices, and any extension before acting.
- Which agencies administer these rules in New York?
- The guide identifies New York State Workers' Compensation Board (WCB). The correct agency depends on the plan and claim jurisdiction.