CMS-1500 mandatory electronic submission takes effect August 1, 2025 — offering significant benefits to health care providers

Effective August 1, 2025, the NYS Workers’ Compensation Board (Board) will require health care providers to submit the CMS-1500 universal billing form electronically, through a Board-approved electronic submission partner. But don’t wait! All providers are encouraged to move to electronic submission as soon as possible to take advantage of key benefits.

For additional information, please access this NYSCA Member's Only link:

For well over a year, the NYSCA Insurance Committee (the NIC) has reported on an antitrust class action lawsuit due to the overlap of Blue Cross Blue Shield (BCBS) plans. The settlement has been approved, including $2.8 Billion in a settlement fund. It is important to note the settlement also includes new requirements on how BCBS processes claims, communicates, and makes payments to healthcare providers. This involves all BCBS plans nationwide. Any health care services rendered over the past 15+ years are eligible to be part of this settlement.

For more information, including how to file a claim and an upcoming webinar on Friday, May 2, 2025, please click the link below:

Beginning 5/19/2025, there is a new mailing address for Medicare Part B claim submitters in Connecticut and New York (Upstate Counties and Queens). 

On Monday, March 24th, the NYS Workers' Compensation Board posted notice regarding changes to durable medical equipment (DME) prior authorization requests (PARs), which also impacts all draft PARs (whether from providers, their delegates, or responses from payer reviewers). 

Last week Excellus BlueCross BlueShield and Univera Healthcare sent letters to their Medicare Advantage members receiving chiropractic care. The NYSCA Insurance Committee (NIC) has spoken with numerous NYSCA doctors regarding this notice and the impact on their practices.

Thank you to those who attended our recent CMS-1500 webinar for health care providers, highlighting that, beginning August 1, 2025, the Board will require health care providers to contract with an electronic submission partner to submit the CMS-1500 universal medical billing form electronically on their behalf. 

If you participate with UnitedHealthcare / Optum you may have received notice of the change in the aforementioned prior authorization program.  Based upon the volume of calls, texts, and emails received by the NYSCA Insurance Committee (NIC), there has been several interpretations of the information published by UHC. For more information please access the following link:

UnitedHealthcare Updates

On November 1, 2024, the Board issued a reminder that it will require health care providers to contract with an electronic submission partner to submit the CMS-1500 universal medical billing form electronically on their behalf beginning August 1, 2025.

The 2025 Medicare Fee Schedule has been posted to the NGS Medicare website.

All Medicare providers and suppliers, including pharmacies, must not bill Medicare beneficiaries in the Qualified Medicare Beneficiary (QMB) eligibility group for Medicare Part A or Part B cost-sharing. This includes Medicare Part A and Part B deductibles, coinsurance, and copayments.

Read More: MLN Matters Fact Sheet October 2024

Mergers. Acquisitions. Affiliations. Increasingly common and complex. These relationships may have no bearing or influence on our practice and ability to provide high quality care to our patients, while others can have a profound impact. A current affiliation awaiting approval from New York State involves CDPHP and Lifetime Healthcare.

Starting today 11/18/2024, healthcare providers won’t have access to beneficiary eligibility information on the NGS Medicare interactive voice response (IVR) system. This includes all beneficiary eligibility information that was obtained under Option 1, Eligibility. The IVR will continue to offer the other non-eligibility transactions.

Beginning Jan. 1, 2025, the $15 copayment for the EmblemHealth-GHl portion of the Senior Care Plan will resume. Senior Care members will be required to pay a $15 copay each time they use the health services listed below. Copays are limited to one copay per provider per date of service.

UnitedHealthcare's Prior Authorization requirements for certain Medicare Advantage members (including UHC and AARP) are now in effect.  For more information, and to join us for a lunch and learn next week, please visit the UnitedHealthcare page in the members' only section of our website:

UnitedHealthcare

Every year there are updates to the ICD-10 codes. Listed below please find the codes most relevant to the Chiropractic profession per the cms.gov website. These changes take effect 10/1/2024. 

Effective August 29, 2024, Humana is requiring prior authorization of certain Medicare Advantage members for chiropractic manipulative therapy rendered on or after August 29, 2024. The NYSCA Insurance Committee (NIC) reached out to Humana over the past week to ascertain whether prior authorization was required for Humana Medicare Advantage members in New York.

The NYSCA continues to communicate with Optum regarding the implementation of the new prior authorization program for AARP and UnitedHealthcare's Medicare Advantage members. We understand many of you have been attempting to determine the impact of this requirement on your practice and the patients you serve.  

On Thursday August 1st many of you received UnitedHealthcare's Provider News email.  That edition of Provider News included a section titled 'Outpatient therapy and chiropractic prior authorization required starting Sept. 1'.  Due to the lack of clarity in that email, the NIC reached out to several members of Optum's team Thursday morning and afternoon to obtain more specific information about the new requirement.

As many of you have been aware, the NYSCA has been in communication with both Highmark and the NYS Department of Financial Services regarding of our member's concerns, including Highmark's implementation of a prior authorization program.  Please join your fellow NYSCA members on Monday, April 29th, 8pm for an open discussion regarding our current understanding of the Highmark Prior Authorization program.