New York medical billing and payer rules

Timely filing in New York

New York law or the federal No Surprises Act?

The plan type decides the pathway. New York law covers fully insured plans, the Empire Plan and the Student Employee Health Plan. Self-funded employer and union plans follow the federal No Surprises Act, which still governs air ambulance disputes everywhere.

Major payers

How does New York Medicaid work, and who runs it?

New York's Medicaid program is run by the New York State Department of Health, and fee-for-service claims go through eMedNY, the state's electronic Medicaid system. The eMedNY call center is 1-800-343-9000.

Two payment channels sit side by side. Fee-for-service claims are billed straight to eMedNY, in the 837P professional or 837I institutional format, through the ePACES web tool, or on paper. Members enrolled in Medicaid managed care are billed to their plan instead, and the plan sets its own rules in its provider contract.

Our Medicaid billing guide covers the national picture; this page covers New York only.

What is New York Medicaid's 90-day rule, and what are the exceptions?

A New York Medicaid claim must reach eMedNY within 90 days of the date of service to be valid and enforceable. That is the rule in 18 NYCRR 540.6(a)(1), which the Department's Guide to Timely Billing quotes. The only way around it is a delay that was outside the provider's control, and then the claim must go in within 30 days of the moment submission came back within the provider's control.

The rule has four clocks. The Department's FOD 7001 says the 30, 60 and 90 day periods are calendar days.

A claim older than 90 days needs a valid delay reason. On the electronic 837, the code goes in loop 2300, segment CLM, element 20. In ePACES it goes in the Delay Reason field. On paper, attach an eMedNY Delay Reason Code form directly behind the claim form.

Code 6, custom-made appliances, is not accepted and is denied. Code 5, billing forms, is not accepted on electronic claims. For code 7, the Guide to Timely Billing says claims must go to Medicare and any other third-party insurer before Medicaid, so keep that payer's remittance as evidence.

Where do Medicaid managed care, NYRx and enrollment fit in?

The 90-day rule governs claims billed to eMedNY. A Medicaid managed care plan is a separate payer, and its filing window comes from its provider agreement and manual. Confirm it in writing.

Pharmacy sits outside the plan. NYRx is the State's Medicaid drug program, and eMedNY labels it the pharmacy benefit transition from Medicaid managed care to NYRx. The eMedNY page says it covers medically necessary prescription and non-prescription drugs, and also practitioner administered drugs, the medical drugs given in an office, clinic or outpatient setting, for fee-for-service members. From November 19, 2026, certain of those drugs need prior authorization.

Revalidation bites now. An eMedNY notice dated August 4, 2026 says New York has begun revalidating all Medicaid providers, to finish by June 2028, with every revalidation submitted in the NYS Medicaid Provider Services Portal. The same notice refers to enrollment moratoriums.

Who is the Medicare contractor in New York?

National Government Services is the Medicare A/B MAC for New York, in Jurisdiction K. The CMS list of MACs by state shows Jurisdiction K covering Connecticut, New York, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont, all under National Government Services. The CMS copy is dated March 2023, so recheck it before a contract decision.

Home health and hospice claims split off. On the same CMS list, New York appears under Jurisdiction 6 for home health and hospice, also National Government Services.

Medicare's timely filing limit is one calendar year after the date of service under 42 CFR 424.44(a)(1). For dual-eligible patients the Medicaid clock is the tight one. Our Medicare billing guide covers appeals and denials.

For dual-eligible patients, eMedNY's professional billing guidelines describe crossover. Bill Medicare first and read the remittance: if it says the claim crossed over to Medicaid, do not bill Medicaid again. If it does not, bill Medicaid directly. Medicare Part C and Part D claims are outside the process.

What does New York's prompt pay law require from insurers?

New York Insurance Law section 3224-a requires an insurer or HMO to pay a claim within 30 calendar days when it was sent electronically and within 45 calendar days when it came on paper or fax, once the duty to pay is reasonably clear. The Department of Financial Services states those periods in its Insurance Circular Letter No. 4 (2021). The insurer must pay a covered person or the provider.

Hospitals get two protections in the same letter. Under 3224-a(i), a hospital whose payment was cut by a recode has 30 calendar days from payment to send records supporting its coding. The insurer must then review them against national coding guidelines. Part YY of Chapter 56 of the Laws of 2020 also limits administrative denials of hospital claims, with exceptions such as a claim submitted late under 3224-a(g), a duplicate or a non-covered benefit.

DFS takes prompt pay complaints at dfs.ny.gov/complaint or (800) 342-3736. For all states side by side, see prompt pay laws by state.

Does New York have its own surprise billing law?

Yes. New York protects patients with state-regulated coverage under Financial Services Law Article 6 and 23 NYCRR 400, and the Department of Financial Services runs the dispute process. CMS's enforcement letter to New York, dated July 29, 2022, treats both as a specified state law for certain items and services furnished to people in insured coverage.

The state law and the federal No Surprises Act divide the work by plan type, not by clinician. The CMS letter says New York has no All-Payer Model Agreement. Where Article 6 applies, the federal IDR process under 45 CFR 149.510 does not apply to that out-of-network rate. Where Article 6 does not apply, the federal process does. Our state surprise billing laws guide explains the method.

Check the ID card. DFS tells patients that a card reading fully insured means New York law, and that one reading self-funded, or not saying fully insured, means the federal law applies.

Which services and bills does the New York law cover?

The New York law covers emergency services in a hospital, including inpatient care that follows an emergency room visit, and surprise bills at an in-network hospital or ambulatory surgical center. DFS's provider page says an out-of-network provider may bill the patient only the in-network copayment, coinsurance or deductible for either. Health plans must pay out-of-network providers directly.

A bill at an in-network hospital or ambulatory surgical center is a surprise bill if no in-network provider was available, the patient did not know of the out-of-network provider, or unforeseen circumstances arose. A patient needs a meaningful chance to choose in-network at least 72 hours ahead.

Some services stay protected even with a signed consent: DFS lists emergency medicine, anesthesiology, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist and intensivist services.

A referral can also create one. If an in-network doctor sends the patient, or a specimen, to an out-of-network provider or laboratory and the patient signed no written consent that the services would be out of network, the bill is a surprise bill. The provider can ask the patient to sign DFS's Surprise Medical Bill Certification Form and sends a copy to the plan.

ER groups should read this with emergency medicine billing, and facilities with hospital and facility billing.

How does a provider start a DFS dispute, and how is it decided?

A provider starts a New York dispute by getting a case number from the DFS portal, completing the IDR Provider and Insurer Application, and sending it with the full fee to the independent dispute resolution entity (IDRE) DFS assigns. The IDRE then decides between the provider's bill and the health plan's payment.

DFS Circular Letter No. 5 (2026) sets the decision window at 45 business days from the IDR entity's receipt of all the information it needs, for disputes submitted on or after August 26, 2026; it was 30 business days before that.

For a plan dispute, the IDRE picks either the provider's bill or the plan's payment. It weighs any gross disparity between the provider's fee and what the plan pays similar providers in the region, the provider's training and experience, a hospital's teaching status and case mix, and the plan's median in-network rate. It may direct a good faith negotiation when the two figures are far apart.

The Empire Plan and the Student Employee Health Plan use a benchmark test. The IDRE chooses the figure closer to the 50th percentile of in-network allowed amounts in the area (DFS cites FAIR Health), and a reasonable provider fee is capped at the 80th percentile.

DFS's 2025 consumer guide reports 3,962 emergency services applications and 13,908 surprise bill applications received in 2024. In emergency services the IDRE found the provider's charge more reasonable 1,465 times and the insurer's payment more reasonable 327 times, with 673 split decisions; another 1,356 were ruled not eligible. See our out-of-network billing and IDR service for how we run both routes.

Which payers matter most in New York?

A New York billing office manages Medicare, Medicaid, the Empire Plan and a regional mix of insurers. DFS's 2025 Consumer Guide to Health Insurers lists the insurers operating in the state, and we state no market share because it gives none.

The guide's HMO table names Capital District Physicians Health Plan, Excellus, Highmark Western and Northeastern New York, HIP, Independent Health, MVP and UnitedHealthcare of New York. Its EPO and PPO table adds Aetna, Anthem HealthChoice Assurance, Cigna, EmblemHealth, Oscar and Oxford. The Empire Plan, which DFS places under state law, belongs on every out-of-network checklist.

This page cites no Department of Health Medicaid managed care plan list, so it does not name those plans.

How does New York differ from New Jersey, Pennsylvania and Connecticut?

Rules differ across the border, so read the plan type first, then the state where care was given, as in our state surprise billing laws guide. See New Jersey, Pennsylvania and Connecticut. Connecticut shares Medicare Jurisdiction K with New York, but its other rules are its own.

How we handle billing in New York

We put the New York clocks in front of the biller on day one: the 90-day Medicaid clock, the delay reason code that applies when a claim runs late, the 120-day commercial submission window and the plan type on the insurance card. Claims go out within 24 hours of charge entry and denials are worked within 48 hours.

For out-of-network emergency and hospital claims, we check whether the plan is fully insured, an Empire Plan or self-funded before choosing between the DFS process and federal IDR, then track open negotiation, dispute submission, fees and deadlines. To talk through your New York payer mix, book a call.