Credentialing in New York

What is specific to New York

New York Medicaid and the managed care plans layered over it each carry different prior authorization rules.

New York’s Medicaid program is NY Medicaid. Practices with a meaningful NY Medicaid mix usually need it worked as its own queue rather than mixed into commercial follow-up, because the submission path, the timely filing window and the appeal route are all different.

Medicare here is adjudicated by National Government Services, jurisdiction JK — shared with Connecticut, Massachusetts and Vermont, but not with New Jersey (Novitas) or Pennsylvania (Novitas). CMS publishes the jurisdictions; checked September 2026.

What a credentialing seat does in New York

Applications, revalidations and payer follow-up, with every enrollment's status visible.

NY Medicaid is not one enrollment but one per plan, and every one of them has a revalidation date that stops payment when it passes. That calendar is the work.

• Initial applications prepared and submitted
• Revalidations tracked ahead of the deadline
• CAQH kept current
• Payer follow-up until an effective date is issued
• Status of every enrollment visible to you
• Worked during New York business hours, not queued overnight

For the statute behind all of this — New York’s prompt-pay deadline, its Medicaid filing limit, and the wrinkle that catches people out here — see the New York billing page.

NY Medicaid, in practice

Primarily managed care, in named product tiers: the NYS Medicaid Update refers to 'Mainstream Medicaid Managed Care, Health and Recovery Plans, and Special Needs Plans,' alongside Managed Long Term Care and Integrated Care for Dual Eligibles, with a residual fee-for-service segment billed through eMedNY. Enrollment reporting is published monthly by NYSDOH. Source: health.ny.gov

New York workers' compensation medical billing is now mandatorily electronic through a Board-approved XML partner, and the payer may lawfully deny for the wrong channel. The WC Board 'replaced 12 custom forms with the CMS-1500 and its use became mandatory in July 2022,' and 'As of August 1, 2025, the Board is requiring all health care providers in the workers' compensation system — regardless of office size or patient population — to submit the CMS-1500 universal medical billing form electronically through a Board-approved submission partner (also known as XML submission partner).' Critically: 'Starting August 1, 2025, the workers' compensation payer can deny payment of services if the CMS-1500 was not submitted through a Board-approved electronic submission partner and the Board will not enforce payment.' A CMS-1500 is also invalid without an attached detailed narrative report, and providers may bill CPT 99080 up to $1.00 per transaction to offset transmission cost. Source: wcb.ny.gov

For enrolment that is not a detail, it is a second application. A carved-out benefit is administered by a different organisation, which credentials separately, on its own timetable, and a provider who is live everywhere else can still be out of network for that one service without anybody noticing until the first claim is denied.

How long you have to file a NY Medicaid claim

90 days from the date of service; finally payable within 2 years, measured from the date the care, services or supplies were furnished. A returned claim not correctly resubmitted within 60 days, or on the second resubmission, is not enforceable.

“must be initially submitted within 90 days of the date the medical care, services or supplies were furnished to an eligible person to be valid and enforceable against the department or a social services district” 18 NYCRR 540.6 — Billing for medical assistance

A claim past that date is not late, it is unpayable, and no appeal recovers it. It is the one queue where a week of nobody working it is money that does not come back — which is the argument for working NY Medicaid as its own queue rather than mixing it into commercial follow-up. Every state’s limit is listed here.

For enrolment that window is the whole risk. A provider seeing patients before their NY Medicaid enrolment completes is accruing dates of service they cannot bill yet, and whether those dates are recoverable depends on two things: how far back the effective date is granted, and whether the filing limit above has already passed by the time the enrolment lands. A retro-effective date that arrives after the window has closed recovers nothing. That is the arithmetic worth doing before a new provider starts, not after.

Working New York hours

New York runs on Eastern time, 10 hours behind our floor in Rawalpindi. To be at a desk for your nine to five, the shift here runs 7pm to 3am, and 6pm to 2am once the clocks go forward. Pakistan does not observe daylight saving, so the shift moves on this side rather than yours.

That is the part that decides whether follow-up happens at all: a payer’s phone lines are open on New York hours and nobody else’s.

What it costs in New York

$2,200

Per seat, per month, in US dollars — $26,400 a year for one full-time person, forty hours a week, on New York hours. No annual contract, no percentage of collections, no setup fee and no software to buy. Seat prices across all roles in New York run $1,500 to $2,500; the full list is published.

That is the entire invoice. Run your own figures against a percentage vendor or a hire rather than take ours.

Getting started in New York

About a week from a signed agreement to a person working your queue, and that week of training is not billed on top. The week, step by step, and what is signed before anyone has access.

If working with staff outside the United States is new to your practice, see how a medical billing company structures that seat and why offshore medical billing does not have to mean losing visibility into the work.

Questions