New Medical Forms
In our last article, we discussed how the C-4 family of paper forms would no longer be accepted from medical providers as of July 1, 2021, and that they would then be required to file Form CMS-1500 instead. As of that date, carriers would also be required to accept these forms electronically as of that date.
Since carriers are required to use Claim Adjustment Reason Codes (CARC’s) as grounds for denial of bills, the Board has now updated Form C-8.1, which has been used to deny medical bills on legal grounds (and also deny future treatment requests), and Form C-8.4, which has been used to raise valuation objections to medical bills (exceeding the Fee Schedule, etc.).
The greatest change is the elimination of the “A” column on Form C-8.1. This eliminates the previous ability to deny further treatment for any reason (such as failing to attend an IME, or the existence of conflicting medical evidence (which has already been deemed obsolete when a C-8.1A was no longer required to accompany a C-4AUTH denial)). However, the ground for denial of requested treatment for a site that it is not established will be transferred to Form RFA-2 when it is updated in the near future. As a result, Form C-8.1 will officially be re-named “Form C-8.1B.”
Also, the Form must still be filed within 45 days of receipt of a bill, with an EOB attached. Both the EOB and the C-8.1B or C-8.4 must indicate that appropriate CARC’s
CARC Crosswalk
Here are some objections that adjusters are most likely to use, as they appear on the current forms, and as they will be implemented on the new forms with EOB’s:
Form C-8.1B
- Current Objection: Claim is Controverted
- CARC Objection: P8: Establishment is Pending, P4: Claim Disallowed
- Current Objection: Prior Authorization not granted for treatment over $1,000.00
- CARC Objection: 198: Authorization Exceeded, 198: Authorization Exceeded (continuous course of treatment over $1,000.00), 198: Authorization not granted for MTG procedure requiring pre-authorization
- Current Objection: Request for treatment has been denied, withdrawn, or refused
- CARC Objection: 39: Services denied when requested
- Current Objection: Treatment not causally related
- CARC Objection: P2: Not a work-related injury,
50: Treatment was to established site, but not causally related,
109: Treatment is for site that is subject of
multiple claims, and the injury is not
related to the claim at issue - Current Objection: Treatment provided within 30 days of accident outside PPO
- CARC Objection: 279: Treatment outside PPO within first 30 days
- Current Objection: Medical report not timely filed or defective
- CARC Objection: 164: Not Timely Filed, 251: Incomplete or Not In Prescribed Format, P13: Not Electronically Submitted
- Current Objection: Medical Appliance Not Covered Under WCL
- CARC Objection: P13: Letter of Medical Necessity Not Included, P13: Insufficient Documentation Provided
- Current Objection: Provider Not Authorized Under WCL
- CARC Objection: P16: Provider Not Authorized
- Current Objection: Incorrect Application of MTG’s:
- CARC Objection: 272: Guidelines Not Met
- Current Objection: Deviation From Guidelines
- CARC Objection: 197: Deviation Without Variance
- Current Objection: Not Consistent With Approved Variance
- CARC Objection: 198: Authorization Exceeded
- Current Objection: Variance Denied Without Review
- CARC Objection: 39: No Timely Review Requested, P30: Exacerbation: Insufficient Documentation, P31: Exacerbation Treatment Still Exceeds MTG, 272: Urine Drug Screens: Insufficient Proof, 272: Urine Drug Screens: Incorrect Testing
Form C-8.4
- Current Objection: Bill Excessive or Beyond Fee Schedule
- CARC Objection: P12: Excessive or Beyond Fee Schedule
- Current Objection: Bill Not Pro-Rated Between Providers
- CARC Objection: B20: Payment Partially Furnished By Other Provider
- Current Objection: Improper CPT Code
- CARC Objection: P13: Improper CPT Codes
- Current Objection: Not By Ground Rules
- CARC Objection: P13: Not By Ground Rules
- Current Objection: Inappropriate
- CARC Objection: 150: Inappropriate
- Current Objection: Concurrent/Overlapping Services
- CARC Objection: 59: Concurrent/Overlapping
- Current Objection: Duplicative/Excessive:
- CARC Objection: 151: Duplicative/Excessive
Conclusion
Ultimately, this is simply a matter of learning a slightly new language, and a new method of communicating that language. As previously noted, the arrival of OnBoard will allow bills, requests, and all forms of denials to be filed electronically.
While Form C-8.1A will no longer be used, it was already headed towards elimination when (a) in 2018, the Board amended its regulations to find that it was no longer necessary to file it along with a C-4AUTH denial; and (b) the need to actually use it, even for non-MTG treatment, was not necessary. Ultimately, any other grounds that would have otherwise warranted the filing of a C-8.1A previously can simply be addressed with a Form RFA-2, just as it already addresses issues of ongoing payments.
Also, now that additional defenses have been formally recognized and become available, carriers will have the advantage of applying more categories to grounds to object to treatment.
