FAQ: Is a Form C-8.1 required if a medical bill is received without a corresponding report?

Where a medical provider has submitted just a bill (not on form HFCA-1500) without the required Form C-4 (“Doctor’s Initial Report”) or C-4.2 report (“Doctor’s Progress Report”), the bill can be objected to without filing a Form C-8.1 (“Notice of Treatment Issue/Disputed Bill”). If the provider then re-submits the bill with the accompanying report, and there is still an objection, then a C-8.1 or C-7 must be filed.

As per 12 NYCRR § 325-1.24, the relevant Regulations states that

any such bill that has remained unpaid shall not be eligible for an administrative award or for arbitration pursuant to [the law] unless the bill was initially submitted to the employer or carrier on a firm prescribed by the Chair (C-4) or standard claim form HFCA 1500 (national version) and completed with such information as may be required.

The Board Form requires completion of the relevant history, objective findings, and diagnosis.

There are numerous other provisions in the Regulations which detail the process for objecting to improper billing or to raise legal objections – in those cases, a C-8.1 or C-7 must be filed. [See 12 NYCRR § 325-1.24(b) et seq.]

Greg Lois is the managing partner of LOIS LLC, a 19-attorney law firm dedicated to defending employers and carriers in New York and New Jersey workers' compensation claims. Greg is the author of a popular series of "Handbooks" on workers' compensation, and is the co-author of the 2016 Lexis-Nexis New Jersey Workers' Compensation Practice Guide. Greg can be reached at 201-880-7213 or glois@lois-llc.com