There are several pieces of Basic Information that are required by New York State. These will appear on every form related to the patient’s Workers’ Compensation claim.
Form Created On – This is the date on which the practice entered information in this window to create the form. Whenever changes are made on this window and saved, the system will update the Form Created On date. Should there be a reason to look up the information entered on past forms, click on the drop down arrow, click on the desired prior date, and the information from that prior date will be displayed.
WCB Case Number – This is a claim identification number issued by the State of New York Workers’ Compensation Board. It must be present on each claim submitted. Type it in to this box.
Carrier Case Number – This is a claim identification number issued by the insurance carrier. It must be present on each claim submitted. Type it in to this box.
Date of Injury – This is the date on which the work related injury occurred. Type it in to this box or double click in the box to open the calendar. If the Date of Injury is today’s current date, click in the box and hit the ‘c’ key on the keyboard to enter the current date.
Health Care Provider Type – The practice must identify the type of Provider that performed the services that are being billed. Currently New York State recognizes only 3 classifications. Select the one that applies to the practice:
1. Physician meaning MD or DO
2. Podiatrist referring to DPM
3. Chiropractor meaning DC
Services Provided by WCB Preferred Provider Organization – If the Provider is part of the New York State Workers’ Compensation Board PPO, then place a check in this box.
The box labeled How and where did the injury/illness happen? is a text box. Type in the detailed information.
To the right of that box is the question of How did you learn of the injury/illness? There are 3 options here:
1. Patient – Select this option if the patient informed the practice of the work related injury or illness
2. Medical Records – Choose this item if the practice obtained the knowledge of the work related injury or illness when reviewing reports or other health records provided to the practice by outside sources, such as other health care facilities
3. Other – Use this item to identify any other means of the practice becoming aware of the work related injury or illness, and enter that source in the text box below the selection
If the patient received treatment for a similar injury or illness in the past, enter the date of the prior injury or illness in the date field labeled Previous Treatment for Similar Injury/Illness.
In the event that the patient was treated by another Provider for this current work related injury or illness, enter the other provider’s name and information in the text box entitled Did Another Provider Treat This Injury?
In the text box for Describe Proposed Treatment enter the specific services and products that are expected to be provided to the patient, as well as any that have already been provided. The items should be clearly spelled out. If abbreviations are used and either the State or insurance carrier do not understand the abbreviation, it will either delay the claim processing or cause it to be rejected. Type the information in the box provided.
Next to the Describe Proposed Treatment, place a check in the box if Authorization is Required. Be sure to attach a detailed request explaining the necessity for the treatment and why it should be authorized.
If the patient had any Pre-Existing Injuries or Symptoms that are affecting this current injury, note them in the text box for Pre-Existing Injuries or Symptoms.
Once the patient has reached the level of Maximum Medical Improvement, return to this window and place a check in the box for Reached MMI. This should only be done when the patient is being dismissed from care for the work related injury or illness.
It is necessary to identify Who Provided the Services to the patient. There are 2 options.
1. I PROVIDED the Services – If the doctor that performed the services is doing the billing, then place the dot in the circle to the left of this choice. That completes the entry for this option.
2. I SUPERVISED the Services – If a staff member (assistant, therapist, etc.) performed the services, that is someone that was supervised by the doctor, then place the dot in the circle to the left of this selection. Under this entry type in the name of the staff member that performed the service, and in the drop down box beneath select the specialty of that individual.