Medical Billing 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 programme 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.

What a medical billing seat does in New York

Aged accounts receivable called until they close, and denials read, appealed and tracked.

In New York the queue that costs the most is NY Medicaid: 90 days from the date of service; finally payable within 2 years, and a claim past that date is unpayable rather than late.

• Worklist worked from the difficult end, not the easy end
• Every call logged with the payer reference and the outcome
• Denials categorised so the same reason stops recurring
• Appeals written and submitted, not just re-bills
• Weekly written summary of what moved and what did not
• Worked during New York business hours, not queued overnight

Most of the New York work we see comes out of New York City, Buffalo and Rochester, though nothing about a seat depends on where your office is — the queue is worked through your system, not from your building.

New York borders 5 states, and practices near those lines almost always carry at least one out-of-state Medicaid enrollment. That is a separate portal, a separate filing window and a separate appeal route from NY Medicaid, and it is the queue that most often goes unworked because it belongs to nobody.

What New York law gives you

30 days for a claim transmitted electronically (internet or e-mail); 45 days for a claim submitted by other means such as paper or facsimile. New York Insurance Law 3224-a(a). The duty does not apply where the insurer's obligation is not reasonably clear or where there is a reasonable, documented basis to believe the claim was fraudulent.

Source.

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

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

On the commercial side the dominant Blue plan here trades as Anthem Blue Cross and Blue Shield — renamed from Empire BlueCross BlueShield effective January 1, 2024 ('Empire Blue Cross BlueShield (Empire) is becoming Anthem Blue Cross and Blue Shield (Anthem) on January 1, 2024'); the underlying entities are Anthem Health Choice HMO, Inc. and Anthem Health Choice Assurance, Inc., 'Independent licensees of the Blue Cross Blue Shield Association.', which matters mainly because its portal and its appeal route are the ones your seat will spend the most time in. Source

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.

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

$1,900

Per seat, per month, in US dollars — $22,800 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 $1,700 to $2,800; 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 on your workflow is not billed on top. The work happens in your own system under a login you issue, so there is nothing to migrate and nothing to install. The week, step by step, and what is signed before anyone has access.

Questions