New York City medical billing for hospitals and ER groups

Major payers

What changed for New York City out-of-network disputes in 2026?

Two changes reached the Department of Financial Services (DFS) dispute process this year, both through Part BB of Chapter 57 of the Laws of 2026, signed on May 28, 2026. DFS explained them in Insurance Circular Letter No. 5 (2026), dated August 13, 2026. The first removed Medicaid managed care. The second brought the Empire Plan and the Student Employee Health Plan in.

The circular letter says a dispute is "filed" when the provider or the insurer enters it into the IDR portal application on the DFS website. That entry date decides which rules apply, so a hospital should log it on the day it submits.

DFS adds that the amendments to 23 NYCRR Part 400 are being adopted on an emergency basis from August 26 while the proposed version moves through the regulatory process. Read the live rule text before you file, because the final wording can differ from the emergency version.

The statewide rules, including the Insurance Law prompt pay clocks, sit on our New York billing rules page. This page covers what is particular to the city.

Which Medicaid managed care plans serve the five boroughs, and where do their disputes go?

Seven Medicaid managed care plans are listed for all five New York City counties, plus three special needs plans, in the Department of Health directory revised September 2026. Because Part BB excluded Medicaid managed care from state IDR, a denial or underpayment from any of them goes through the plan's own appeal process and your provider agreement. A hospital cannot file it with DFS.

A fee-for-service Medicaid claim is a different channel and follows the eMedNY clocks on the state page. Check the member's coverage first so the claim goes to the right channel.

The appeal windows for these plans are set in each provider agreement and manual. Keep each plan's written deadline in your denial work queue. Our denial management team does this plan by plan.

How do Empire Plan disputes work for a New York City teaching hospital?

For disputes filed on or after August 26, 2026, the Empire Plan and the Student Employee Health Plan use the state IDR process, and the IDR entity must pick whichever of the plan's payment or the provider's fee is closest to an allowed benchmark. The circular letter defines the benchmark as the 50th percentile of allowed amounts for the same service, specialty and area in a benchmarking database. A provider cannot send the same dispute through federal IDR and the state process: one already decided or pending at federal level blocks the other.

The letter also sets a ceiling. If the IDR entity finds the provider's fee reasonable, the State Plan cannot owe more than the maximum fee, which the law defines as the 80th percentile of allowed amounts.

Teaching hospitals get a different rule for physicians. Under Financial Services Law 604(b)(5), the new State Plan criteria do not apply to a physician employed by an Article 28 general hospital, by its affiliated medical school, or by a captive group practice owned by hospital employees. The IDR entity uses the older criteria in 604(a) instead.

Plan type still comes first. Self-funded employer and union plans stay with the federal process, which our state surprise billing laws guide lays out.

Which New York City hospitals are Level I trauma centers, and does it change the billing?

The Department of Health's trauma center list shows twelve Level I adult trauma centers in New York City across the Bronx, Brooklyn, Manhattan, Queens and Staten Island. Five of them are NYC Health + Hospitals sites: Jacobi, Lincoln, Kings County, Bellevue and Elmhurst. The list tells you which hospitals take the highest-acuity emergency patients, and Bellevue's own release shows where those patients come from.

Bellevue's own April 9, 2026 release shows how far those patients travel. It says the trauma program serves patients from all five boroughs, Long Island and Westchester, and that 1,986 adults were admitted for trauma care in 2025. A patient from Westchester or Long Island may carry coverage governed by a different county's insurer and a different plan type, so confirm fully insured or self-funded on every one.

Harlem Hospital Center, Mount Sinai Morningside, Brookdale, NewYork-Presbyterian Brooklyn Methodist and SBH Health System appear as Level II adult centers on the same list.

For billing, flag accounts from these sites when an emergency visit turns into an inpatient stay. Hospital and facility billing covers the institutional claim, and the state page explains that DFS counts inpatient care after an ER visit as part of the emergency services scope.

What happens to claims when a New York City health system and an insurer part ways?

Claims are paid by the network status that applied on the date of service, so a contract break splits one patient's care into in-network and out-of-network claims. The 2026 Mount Sinai and Anthem dispute is the clearest recent example in the city.

Mount Sinai's own release of March 16, 2026 said its hospitals, facilities and physicians were out of network with Anthem Blue Cross Blue Shield at that time. It also said Anthem owed Mount Sinai more than $450 million for care already delivered to Anthem members. Those figures are Mount Sinai's statements.

Treat network status as a date-of-service question and check network status on the payer portal for each claim. The same discipline applies to any system, including NYC Health + Hospitals, NewYork-Presbyterian, NYU Langone, Montefiore and Northwell.

• Record the payer's network status on the date of service, not the date you bill.
• Keep any payer termination or network notice with the account, so you can show which contract applied on that date.
• Send out-of-network claims to open negotiation before the dispute window closes. Our out-of-network billing and IDR page has the sequence.
• Check Anthem rules for the claim format that applies once a system returns to network.

How do New York City no-fault auto claims interact with hospital billing?

Motor vehicle accident injuries fall under the no-fault law, Insurance Law Article 51, and the DFS fee schedule, Regulation 83 at 11 NYCRR Part 68, sets what a hospital can charge. DFS lists the Hospital Facility Form NF-5 among its official no-fault forms. Inpatient stays are billed on the Department of Health's DRG system under Regulation 83 section 68.2 and Public Health Law 2807-c.

DFS says in its Regulation 83 FAQs that a DRG rate cannot be calculated until discharge because the discharge diagnosis is one of its inputs. Any initial payment made at admission is reconciled at discharge, and a hospital may resubmit an amended inpatient bill if the DRG rate was calculated wrongly.

For ambulance transport, the same FAQs say Part G of Regulation 83 caps the charge at the local prevailing charge in the area where the service was rendered. Plan the sequence with our workers' comp and no-fault billing service.

What stays the same in New York City, and where is it covered?

Medicare claims from the five boroughs go to National Government Services, the A/B MAC for Jurisdiction K, per the CMS list of MACs by state. The Medicaid 90-day clock, the Insurance Law prompt pay periods and the DFS provider steps are statewide, so they live on the New York state page rather than here. Our Medicaid and Medicare guides cover the national rules.

For an upstate comparison, see Buffalo.

How we handle billing for New York City groups and facilities

We work with New York City hospitals, emergency departments and freestanding ERs remotely from our team offices and our registered office in Richmond, KY. We have no New York office. For hospital claims we prepare UB-04 institutional claims with revenue-code validation, bill type, patient status and authorization checks, then reconcile payments and work denials within 48 hours.

For out-of-network emergency claims, we check eligibility and plan type first, then manage open negotiation, dispute submissions, fees and deadlines under federal IDR or the applicable state pathway, with a decision win rate and award-to-offer ratio tracked on case data. To talk through your payer mix, book a call.