New York has some of the most detailed claim payment laws in the country. Payers have strict deadlines to pay, firm limits on how far back they can take money back, and a state dispute process for surprise bills. Medicaid has its own enrollment system and a 90-day filing limit. And in 2026, the Essential Plan changed who qualifies. A New York practice that knows these rules collects more of what it bills. Maximum Billing handles medical billing for New York physician practices and specialty groups, from New York City and Long Island to the Hudson Valley and upstate.
New York is one of the twelve states where we bill. Schedule a consultation or call 800-820-0364.
New York Medical Billing at a Glance
- Prompt pay: 30 days for undisputed electronic claims and 45 days for paper claims, with interest when payers are late.
- Recoupment limit: 24 months for most overpayment recovery, with 30 days’ written notice.
- Surprise bills: the patient pays in-network cost-sharing, and payment disputes on state-regulated plans go to the Department of Financial Services.
- Medicaid: enrollment through eMedNY, an ETIN for electronic claims, and 90 days to file.
- Medicare: National Government Services, Jurisdiction K.
- Credentialing: a 60-day decision deadline, with provisional credentialing for some physicians joining groups.
Prompt Pay, Filing Limits, and Recoupment
Under New York Insurance Law §3224-a, payers must pay undisputed claims within 30 days of receipt when they are submitted electronically, and within 45 days when they are sent on paper or by fax. Late payments carry interest at the greater of 12% a year or the rate set by the Commissioner of Taxation and Finance.
The same law sets the filing window. Unless a contract allows more time, claims are due within 120 days of the date of service. Medicaid and Child Health Plus contracts can set 90 days. A payer can deny in full any claim submitted more than 365 days after the service. A late claim that qualifies for reconsideration can still be cut by up to 25%.
Section 3224-b limits how far back a payer can go to recover an overpayment: generally 24 months from the original payment. The payer must give 30 days’ written notice that names the patient, date of service, amount, and reason. Fraud, abusive billing, self-insured plans, and government programs are exceptions. When a recoupment notice arrives, we check it against those rules before money is taken back.
Surprise Bills and Out-of-Network Claims
New York’s surprise bill law, in Article 6 of the Financial Services Law, protects patients who are treated by an out-of-network provider at an in-network hospital or surgical center without a real choice. It also protects patients referred by an in-network doctor to an out-of-network provider without written consent, and it covers emergency services. The patient owes only in-network cost-sharing, and the provider cannot balance bill.
For fully insured, New York-regulated plans and the Empire Plan, payment disputes go to the Department of Financial Services’ Independent Dispute Resolution process. Self-funded employer plans fall under the federal No Surprises Act instead. Before an out-of-network claim is billed, we confirm which set of rules applies. Our out-of-network billing services page covers how we bill these claims.
New York Medicaid
- Enrollment: through the eMedNY Provider Services Portal. An NPI and a New York license do not mean a provider is enrolled. The approval letter gives the MMIS provider ID and the effective date.
- ETIN: an Electronic Transmitter Identification Number is required to submit claims electronically. New enrollees and providers joining an existing ETIN use different forms.
- Timely filing: initial claims are due within 90 days of the date of service, and resubmissions within 60 days of notice. When a delay was outside the provider’s control, there are limited exceptions, with an absolute limit of two years.
- Pharmacy carve-out: since April 1, 2023, pharmacy benefits for most Medicaid managed care members are covered through NYRx, the state’s fee-for-service pharmacy program, rather than the managed care plan.
- Compliance programs: the Office of the Medicaid Inspector General requires a compliance program for any provider that claims or receives $1 million or more from Medicaid in a 12-month period.
The Essential Plan Changed in 2026
On July 1, 2026, the Essential Plan moved back to the federal Basic Health Program, and its income limit dropped from 250% to 200% of the federal poverty level. Hundreds of thousands of New Yorkers lost Essential Plan coverage. For practices, that means a patient who was covered in the spring may now have a Qualified Health Plan, Medicaid, or no coverage at all. We check eligibility before each visit so these changes show up before the claim does.
Medicare and the Empire Plan
Original Medicare claims in New York go to National Government Services, the Medicare Administrative Contractor for Jurisdiction K. Medicare Advantage plans are billed to each plan under its own rules, and Special Needs Plans make up a large share of New York’s Medicare Advantage enrollment.
The Empire Plan, the main plan for New York State and many local government employees, splits its benefits among administrators. UnitedHealthcare handles medical and surgical claims, Anthem Blue Cross handles hospital claims, and Carelon Behavioral Health handles mental health and substance use claims. A claim sent to the wrong administrator will deny.
No-Fault and Workers’ Compensation
Practices that treat auto accident and workplace injury patients face separate rules:
- No-fault auto: physicians submit proof of claim on form NF-3 within 45 days of the service. Fees are capped at the Workers’ Compensation Board fee schedules.
- Workers’ compensation: since August 1, 2025, bills must be sent electronically on the CMS-1500 through a Board-approved submission partner. Paper bills are not paid. Bills are due within 120 days of the date of care, and prior authorization requests go through the Board’s OnBoard portal.
- Fee schedule: the Board published a revised proposal to update its medical fee schedule in September 2026. It had not been adopted at that point.
Credentialing New York Physicians
Under Insurance Law §4803, insurers must decide on a complete credentialing application within 60 days. A newly licensed physician, or one who has moved to New York, may join a participating group. If the insurer has not decided by day 61, the physician is provisionally credentialed and can see in-network patients. If the application is later denied, the group must refund anything paid above out-of-network benefits. That makes accurate, complete applications worth the time.
We handle CAQH profiles, Medicare enrollment through PECOS, eMedNY enrollment, and commercial plan applications. We also track each clinician’s status with every plan. See our medical credentialing services and, for multi-clinician practices, our group practice billing services.
Where New York Medical Claims Go Wrong
- Medicaid claims filed after the 90-day limit.
- Electronic claims rejected because the ETIN was never set up or linked.
- Empire Plan claims sent to the wrong administrator.
- Recoupments accepted without checking the 24-month limit or the notice rules.
- Late payments never checked for the interest the law requires.
- Patients who lost Essential Plan coverage in 2026 but were seen on old insurance information.
Our claims denial management and accounts receivable management services explain how we work these claims.
What Our New York Medical Billing Includes
- Eligibility and benefits checks for commercial, Empire Plan, Medicaid managed care, Essential Plan, Medicare, and Medicare Advantage patients.
- Charge entry, coding review, and clean claim submission.
- Payment posting, with late payments and underpayments flagged.
- Review of recoupment notices.
- Denial follow-up and appeals.
- Credentialing, revalidation, and enrollment updates for every clinician and location.
We work inside the practice management system you already use. A Business Associate Agreement is signed before any patient information is shared, and every team member completes HIPAA certification. As of 2026, our clients’ claims reach a 91% clean claim rate, and their accounts receivable average 34 days.
New York mental health practices can see our New York behavioral health billing page. For practices in our other states, see our national medical billing services page.
Frequently Asked Questions
How fast do New York insurers have to pay a claim?
Within 30 days for undisputed electronic claims and 45 days for paper claims, under Insurance Law §3224-a. Late payments carry interest.
What is the timely filing limit for New York Medicaid?
90 days from the date of service for an initial claim, with limited exceptions for delays outside the provider’s control.
Can an insurer take back a payment from two years ago?
Generally no. Section 3224-b limits most overpayment recovery to 24 months from the original payment, with 30 days’ written notice. Fraud, abusive billing, self-insured plans, and government programs are exceptions.
Do you work in our practice management system?
Yes. We work inside the system your practice already uses.
Start With a New York Billing Review
If Medicaid deadlines, recoupments, or payer rules are costing your practice money, tell us about your payers and software. We will review your aging report and recent denials with you. Contact us or call 800-820-0364.