Workers' comp billing services and no-fault billing
Workers' comp and no-fault claims are paid under state rules, so the fee schedule, the filing deadline and the payment clock change with the state. We bill these claims with the carrier, claim number and state rule confirmed before the bill goes out.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · Last reviewed October 2026
In short: workers' comp pays job-related injury care and no-fault pays auto accident care, each under state rules. We check the carrier, claim number and state fee schedule first, track the carrier's clock, and dispute short payments through the state process.
How is workers' comp billing different from health insurance billing?
Workers' comp pays for care of a job-related injury under a state system, so the state sets the fee schedule, the bill format and the clocks. Health insurance follows the plan contract and the payer's own rules, and the state has far less say in either.
No-fault (also called PIP, personal injury protection) is the auto version: the auto policy pays accident medical bills regardless of fault. The payer is also different. A workers' comp bill goes to the employer's insurance carrier, or to a self-insured employer or its claims administrator, not to the patient's health plan.
| Row | Workers' comp | No-fault (PIP) | Group health |
|---|---|---|---|
| Pays for | Job-related injury or illness | Motor vehicle accident injuries | Covered medical care |
| Billed to | Employer's carrier or claims administrator | The auto insurer | The patient's health plan |
| Price set by | State fee schedule | State rules and fee schedule where one exists | Contract rates or plan allowed amounts |
| Rules come from | State agency | State insurance department | Plan contract and payer manual |
Which fee schedule and deadlines apply? Three state examples
The fee schedule, filing deadline and payment clock all come from the state where the claim sits, and they differ. Below are three states whose agencies publish the rule on their own sites. They show how far apart the rules run. They are not a list of every state.
California workers' comp (Division of Workers' Compensation)
California prices physician services on the Physician Fee Schedule. Under 8 CCR 9789.12.1, maximum fees for physician and non-physician practitioner treatment rendered on or after January 1, 2014 are capped by that schedule, which is made up of sections 9789.12.1 through 9789.19.1.
The Division of Workers' Compensation (DWC) states that medical bills must be submitted within 12 months of the date of service. Its FAQ also says an uncontested bill must be paid within 45 days of receipt, or 60 days if the employer is a governmental entity. If the claims administrator contests, denies or finds the bill incomplete, it must notify the provider within 30 days of receipt.
New York workers' comp (Workers' Compensation Board)
New York no longer takes paper bills for workers' comp treatment. The Workers' Compensation Board (WCB) states that as of August 1, 2025, all treating healthcare providers must submit the CMS-1500 electronically to be paid for services.
A paper CMS-1500 sent on or after that date gets no payment. The payer's explanation references CARC 16 and RARC N34, which tell you the bill was not submitted electronically. The WCB says you then resubmit through an approved electronic submission partner within 120 days from the day care was rendered.
New York no-fault (Department of Financial Services)
New York no-fault is auto PIP, governed by Insurance Regulation 68 (11 NYCRR Part 65). Basic no-fault coverage pays up to $50,000 per person for items that include all necessary doctor and hospital bills, payable under fee schedules established or adopted by the New York State Department of Financial Services (DFS).
Regulation 68's prescribed policy language requires written proof of claim for health service expenses as soon as reasonably practicable and no later than 45 days after the date services are rendered, unless the injured person shows clear and reasonable justification for the delay.
What do you need to bill: claim number, carrier and employer?
You need the carrier or claims administrator, the carrier's claim number, the employer's name and the injury date before you send a bill. Without them the bill goes to the wrong place or fails the carrier's match, and the clock keeps running.
Capture these at the front desk, not in billing. We use this checklist when we set up a workers' comp encounter.
- Carrier or claims administrator: name, claims address or electronic payer ID, and the adjuster's phone number.
- Claim number: the carrier's number, not the patient's member ID. A brand-new injury may not have one yet, so record the date the carrier was notified.
- Employer: legal name, address and a contact who can confirm the injury.
- Date of injury, and a copy of the patient's group health card in case the claim is denied.
The first report of injury is the employer's report of the injury to its carrier. The state decides who files it and when, and it is what opens the claim and creates the claim number.
How does a workers' comp bill get from visit to payment?
The bill moves through six steps, and most delays happen at the first two. The steps are the same in every state. The forms, clocks and payment rules change.
Professional services go on the CMS-1500 and facility services on the UB-04. Our medical billing team handles both. Our eligibility verification work covers step one.
How does fee schedule pricing change what you collect?
A state fee schedule sets the most a carrier must pay for a service, so your charge master does not set your payment. A fee schedule is the state's published list of maximum allowable payments by code.
California shows why the date matters. 8 CCR 9789.12.1 covers treatment rendered on or after January 1, 2014 and sends that treatment to the Physician Fee Schedule.
In New York no-fault, the regulation says doctor and hospital bills are payable in accordance with fee schedules established or adopted by DFS. That is the benchmark for a short-pay review.
A clinic charges 200 for a service. The state schedule allows 120. The carrier pays 120 and the explanation reads as a fee schedule reduction. Nothing is owed, and the 80 difference is not billed to the patient. If the carrier had paid 90, the 30 gap would be a short payment to dispute.
What happens in bill review, and how do you dispute an underpayment?
Carriers send workers' comp bills through bill review, where a reviewer or software reprices the bill and may cut lines. You dispute by asking for correction under the state's own process, usually first with the carrier and then with the state agency. The steps and deadlines belong to the state, so we pull the current ones for each claim.
Payer clocks are published. In California, the DWC FAQ gives the claims administrator 45 days to pay an uncontested bill and 30 days to say the bill is contested, denied or incomplete. In New York no-fault, benefits are overdue if not paid within 30 calendar days after the insurer receives proof of claim (11 NYCRR 65-3.8).
Under 11 NYCRR 65-3.5(b), a no-fault insurer must request additional verification within 15 business days of receiving the prescribed verification forms. Section 65-3.9 sets interest on overdue benefits at two percent per month.
This is denial management with a state rulebook. We read the explanation of review (the workers' comp version of an EOB) line by line against the fee schedule.
What if the injury claim is denied or the bill goes to the wrong carrier?
If the carrier denies the injury as not work related, the bill needs a new payer. If you billed the wrong carrier, the time to correct it depends on the state. Act on the day the denial arrives.
Medicare's rules show the pattern. CMS says Medicare generally will not pay for an injury or illness covered by workers' compensation, but if workers' comp denies a claim as not covered, the claim may be filed with Medicare. Keep the carrier's denial letter, because it supports the next claim.
A wrong-carrier error has no single national fix. New York's no-fault rule (11 NYCRR 65-3.5(l)) tells insurers to give appropriate consideration to inadvertent submission to the incorrect insurer when they review late proof of claim.
| Situation | What we do first |
|---|---|
| Carrier denies the injury as non-work-related | Get the denial in writing, then bill the patient's health plan or Medicare with it attached |
| Bill sent to the wrong carrier | Find the right carrier, resubmit at once with a note, and check the state's late-filing exception |
| Payment below the fee schedule | Compare with the schedule line, then dispute under the state process |
When is Medicare the secondary payer to workers' comp or no-fault?
Workers' comp pays first for job-related injury, and no-fault or liability insurance pays first for accident-related care. Medicare is secondary payer in both cases. The CMS Medicare Secondary Payer (MSP) page says workers' compensation pays primary for job-related illness or injury, and no-fault or liability insurance pays primary for accident-related care. See our Medicare Secondary Payer rules page.
A conditional payment is a payment Medicare makes for services another payer may be responsible for. CMS says it is conditional because it must be repaid to Medicare when a settlement, judgment, award or other payment is made.
Settlements add one more item. A Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) allocates part of a settlement to pay for future medical services related to the injury. CMS reviews proposals when the claimant is a Medicare beneficiary and the total settlement is greater than $25,000, or when Medicare enrollment is reasonably expected within 30 months and the settlement for future medical and disability or lost wages is expected to exceed $250,000.
Do urgent care centers and ERs bill workers' comp the same way?
The claim steps are the same. Urgent care and emergency departments see many first visits for new injuries, often before a claim number exists, so front-desk capture matters more.
We cover occupational visits in urgent care billing and the wider urgent care billing guide.
If your network is built around walk-in injuries, see how we work with urgent care networks. State-by-state rules will sit on our state pages as we publish them.
How we handle workers' comp and no-fault billing
We bill workers' comp and no-fault encounters the way we bill everything else: claims sent within 24 hours of charge entry, and denials worked within 48 hours. The difference is that each claim is checked against its own state's rules first.
Our accounts receivable recovery team works old workers' comp balances too.
To see how this fits your clinics, book a call. Our services overview lists everything else we run, and the rules library holds the reference pages.
- Medicare Secondary Payer · CMS
- Workers' Compensation Medicare Set-Aside Arrangements · CMS
- 8 CCR 9789.12.1 Physician Fee Schedule · California DIR, Division of Workers' Compensation
- 8 CCR 9792.5.1 Medical Billing and Payment Guide · California DIR, Division of Workers' Compensation
- DWC FAQs on standardized paper billing · California DIR, Division of Workers' Compensation
- What Providers Need to Know (archived update, Aug 2025) · New York Workers' Compensation Board
- What Providers Need to Know (archived update, Mar 2026) · New York Workers' Compensation Board
- Insurance Regulation 68 (11 NYCRR Part 65), full text · New York State Department of Financial Services
We check every rule, code and deadline against the official source. See our editorial policy.
Who we do this for
Common questions
Straight answers from the team that does the work.
Ask a billing lead directly. A 20-minute call, Monday to Friday, 9am to 5pm Eastern.
01How is workers comp billing different from health insurance billing?
Workers' comp pays for job-related injury under a state system, so the state sets the fee schedule, forms and payment clocks. Health insurance follows the plan contract. A workers' comp bill goes to the employer's carrier with a claim number, and a wrong payer choice costs more because the clocks are short.
02What is the filing deadline for workers comp bills?
Each state sets its own. California's DWC says medical bills must be submitted within 12 months of the date of service. In New York, a paper CMS-1500 that is rejected must be resubmitted electronically within 120 days from the day care was rendered. Check the state before you bill.
03What happens if I bill the wrong carrier?
The bill is denied or ignored and the clock keeps running. Find the right carrier and resubmit quickly with a note. Late-filing rules differ by state. New York no-fault tells insurers to give appropriate consideration to inadvertent submission to the incorrect insurer.
04What fee schedule applies to workers comp claims?
The one your state sets for the date of service. California's Physician Fee Schedule governs physician treatment rendered on or after January 1, 2014 (8 CCR 9789.12.1). New York no-fault bills are payable under fee schedules established or adopted by DFS.
05How do I dispute a workers comp underpayment?
Compare the payment with the state fee schedule line for the date of service, then ask the carrier to correct it, using the explanation of review. If it does not, use the state's dispute process, which varies by state. Watch the dates on no-fault claims, since interest on a disputed amount can stop until arbitration or suit starts.
06What is no-fault (PIP) billing and which states use it?
No-fault, also called PIP, is auto insurance that pays accident medical bills regardless of fault. It applies in specific states, each with its own rules. New York is one: Regulation 68 gives basic coverage of up to $50,000 per person. We do not list every no-fault state here.
07What forms do workers comp carriers require?
The CMS-1500 for professional services and the UB-04 for facility services are the usual forms, but requirements are state-specific. New York requires electronic CMS-1500 submission. New York no-fault accepts the NF-5 hospital facility form, or an NF-5 with a uniform billing form.
08How do you handle claims where the injury claim is disputed or denied?
We get the denial in writing and bill the next payer with it attached. CMS says that if workers' compensation denies a claim as not covered, the claim may be filed with Medicare. We also check whether the denial can be appealed under the state process.
09How do you verify the carrier and claim number at the front desk?
Ask for the carrier name, the claim number and the adjuster's phone, then call the adjuster to confirm the claim is open and covers the visit. Record the employer and injury date. If no claim number exists, record the date the carrier was notified and hold the bill.
10How long do workers comp carriers take to pay?
It depends on the state. California's DWC says an uncontested bill must be paid within 45 days of receipt, or 60 days for a governmental employer. New York no-fault benefits are overdue if unpaid 30 calendar days after the insurer receives proof of claim.
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