Guides New York and Long Island

New York medical billing rules other states don’t have

By Marlow’s billing manager, 20+ years in medical billing, former billing manager at Mount Sinai South Nassau, Oceanside · Updated November 9, 2026 · 10 min read

The short answer

New York gives practices a 120-day minimum to file with state-regulated plans, 30-day prompt pay with interest, and a state IDR process for surprise bills. Most of it stops at self-funded employer plans, which follow federal rules instead.

New York has billing rules that protect practices, but only on some patients. For plans regulated by New York, the law sets a 120-day minimum to file a claim, requires payment of clean electronic claims within 30 days, charges plans interest when they’re late, and sends surprise bill payment disputes to a state independent dispute resolution process. eMedNY fee-for-service Medicaid has its own 90-day rule, and New York limits how practices can collect on patient medical debt. Self-funded employer and union plans sit outside most of this, so the first thing to know about any claim is which kind of plan it is.

This guide lists the rules, the statute or regulator page behind each one, and what they change in a billing office. It is general information, not legal advice. Read the linked text, and talk to your health care attorney before you rely on any of it in a dispute.

First question: is the plan regulated by New York?

Most of the rules below apply to insurers and HMOs licensed in New York. They don’t apply to self-funded (also called self-insured) employer or union plans, which are governed by federal law. NY DFS says so directly: its surprise bill guidance lists “self-funded coverage” among the plans the state rules don’t reach, and points those patients to the federal No Surprises Act instead (DFS out-of-network law guidance, updated August 2026).

How to tell at the front desk:

Read the ID card. DFS tells consumers that a card saying “fully insured” means New York law applies, and a card saying “self-funded”, or not saying “fully insured”, means it probably doesn’t (DFS surprise medical bills).
A big carrier logo proves nothing. Carriers administer self-funded plans alongside their insured business. EmblemHealth’s timely filing page, for example, says self-funded groups “may set their own claim filing limits” that override its published ones (EmblemHealth timely filing). The same carrier can owe you the 120-day floor on one patient and not on the next.
Union funds play by their own rules. The 1199SEIU Benefit Funds, for example, say on their provider site that state insurance laws on overpayment recovery don’t apply to them “because the Benefit Funds are not insurance companies” (1199SEIU claims and reimbursement).
The Empire Plan is an exception the other way. NYSHIP’s Empire Plan is a state employee plan, and DFS says New York’s surprise bill protections and IDR apply to it (DFS IDR).

Record “fully insured” or “self-funded” in the patient’s insurance profile at check-in. It decides which deadlines and dispute paths apply later.

The 120-day filing floor

Insurance Law §3224-a(g) says claims must be “initially submitted” within 120 days after the date of service to be valid and enforceable against a New York-regulated insurer or HMO. A contract can give you more time, but not less (NY Ins. Law §3224-a, as of November 2026).

Two details from the statute that national payer manuals tend to leave out:

Medicaid managed care and Child Health Plus contracts can be shorter, but never under 90 days. The plan and the provider can agree to a different period for those programs.
Late claims can sometimes be reconsidered. Under §3224-a(h), a participating provider can ask for reconsideration of a claim denied only because it was late. The plan must pay if you show the delay came from an “unusual occurrence” and you have a pattern of filing on time. The plan can cut the payment by up to 25%, and the right ends at 365 days after the date of service.

National manuals often say 90 days for participating providers. Cigna’s claims page, for example, lists 90 days for participating providers and then says the deadline can be longer where “applicable law requires a longer filing period” (Cigna, when to file claims). On a New York fully insured plan, the statute is the longer period. Payer-by-payer limits are in our New York timely filing table.

Prompt pay: 30 days, then interest

Section 3224-a(a) requires a New York-regulated plan to pay a clean claim within 30 days of receiving it electronically, or 45 days for paper or fax. If a claim is in dispute, §3224-a(b) requires the plan to pay the undisputed part and, within 30 days, tell you in writing what it is denying and why, and what information it still needs (NY Ins. Law §3224-a).

If the plan misses those standards, §3224-a(c) adds interest at the greater of 12% a year or the corporate tax rate set by the Commissioner of Taxation and Finance, counted from the date payment was due. Interest under $2 on a claim doesn’t have to be paid.

What this means in practice:

Submit electronically. The 30-day clock is only for claims sent electronically.
Keep the 277CA or clearinghouse acceptance report. It is your proof of when the plan received the claim.
When a fully insured claim sits past 30 days with no request for information, ask about it in writing and cite §3224-a.

Overpayment clawbacks: 30 days’ notice, 24-month limit

Insurance Law §3224-b(b) controls how New York-regulated plans take money back (NY Ins. Law §3224-b, as of November 2026):

Except for duplicate payments, the plan must give 30 days’ written notice before recovering an overpayment. The notice must name the patient, date of service, payment, proposed adjustment and a reasonably specific reason.
The plan must have a written process for providers to challenge a recovery.
The plan can’t start recovery more than 24 months after you received the original payment. That limit doesn’t apply to suspected fraud or abusive billing, to recoveries a self-insured plan asks for, or to state and municipal employee coverage.
If you claim an underpayment, the plan can offset it against overpayments going back as far as the underpayment you’re claiming.

Before you open an old underpayment dispute, check whether it gives the plan grounds to reopen older claims.

Surprise bills and the DFS IDR process

New York’s surprise bill law is in Financial Services Law Article 6. DFS’s summary of §603(h) covers two situations: services from a non-participating provider at a participating hospital or ambulatory surgery center (for example, when no participating provider was available), and a referral by a participating physician to a non-participating provider without the patient’s explicit written consent. In those cases the patient owes only in-network cost-sharing (DFS out-of-network law guidance).

The referral rule catches independent practices. If you send a specimen to an out-of-network lab, or refer to an out-of-network specialist, without the written consent the law describes, that bill can become a surprise bill. Put an out-of-network referral consent form in your referral workflow, and have your attorney check its wording against the statute.

When the plan and the out-of-network provider disagree on payment, either side can file with New York’s independent dispute resolution (IDR) process. DFS’s guidance says a dispute must be filed within three years of the date the plan made the original payment. It also says the New York IDR doesn’t cover Medicaid managed care, and that disputes for self-funded plans go to the federal IDR process (the Empire Plan is the exception). The provider application and instructions are on the DFS IDR page.

eMedNY fee-for-service Medicaid: the 90-day rule

For fee-for-service Medicaid billed through eMedNY, the General Billing manual says claims must be “initially submitted within 90 days of the date of service” unless the delay was outside the provider’s control (eMedNY General Billing, version 2025-1). The rest of the rule:

Late claims need a delay reason code. Each code has its own window, usually 30 days from when submission came within your control, and you must keep documentation of the reason.
Corrections go in as adjustments within 60 days of notification. A claim not resubmitted correctly within 60 days, or still not payable after the second resubmission, is no longer valid.
Two years is the hard stop. Claims must be submitted and payable within two years of the date of service. Older claims are considered only if the delay was the Department’s error or a court ordered payment.

The delay codes and their windows:

Code	Delay reason	Window
1	Patient’s eligibility unknown	30 days from notice of eligibility
2	Litigation	30 days from when it came within your control
3	State authorization delay	30 days from notice
4	Delay in certifying the provider	30 days from notice
7	Third-party (Medicare, other insurer) processing delay	30 days from when it came within your control
8	Delay in eligibility determination	30 days from notice
9	Original claim denied for a non-timeliness reason	60 days from notice
10	Administrative delay in prior approval	30 days from notice
11	Other (listed situations only)	Usually 60 days from notice
15	Natural disaster (declared emergency)	30 days from when it came within your control

Source: eMedNY General Billing manual, version 2025-1, June 2025.

Medicaid managed care plans set their own terms

Each Medicaid managed care plan’s contract and manual set its own billing rules, within the 90-day statutory minimum. Two examples, read in November 2026:

Fidelis Care says Medicaid and Child Health Plus claims must be submitted within 90 days, and corrected claims within 60 days of the remittance advice (Fidelis Care provider manual, v26.1).
Healthfirst points to the provider’s agreement for the filing period, but says it won’t pay any claim submitted more than 180 days after the date of service (Healthfirst New York provider manual, updated November 2026).

One more rule applies across all of them. The 21st Century Cures Act requires every Medicaid managed care network provider to be enrolled with the state Medicaid program, so a plan can remove you from its Medicaid network if you aren’t enrolled with eMedNY (eMedNY managed care network provider enrollment). Our credentialing guide covers the steps.

Patient balances: medical debt rules

New York has two statutes that affect how a practice collects from patients. They’re described here so you know they exist. How they apply to your accounts is a question for your attorney.

Three-year limit on lawsuits. CPLR §213-d says an action on medical debt by a hospital or a licensed health care professional must be started within three years of treatment (NY CPLR §213-d).
No credit reporting. Public Health Law §4926, from the Fair Medical Debt Reporting Act signed in December 2023, says hospitals, licensed health care professionals and ambulance services may not furnish any part of a medical debt to a consumer reporting agency. Contracts with collection agencies must also prohibit reporting (NY PHL §4926; Governor’s announcement).

If a collection agency handles your patient accounts, check that the contract includes the no-reporting clause.

No-fault and workers’ comp: a pointer

No-fault auto and workers’ compensation are separate systems with their own fee schedules, forms and deadlines. Two facts worth knowing before you take those patients:

Workers’ comp bills must be electronic. The NY Workers’ Compensation Board made the CMS-1500 mandatory in July 2022. Since August 1, 2025, providers must submit it electronically through a Board-approved submission partner, and payers can deny bills that weren’t sent that way (WCB CMS-1500 overview).
No-fault has a 45-day proof-of-claim deadline. The mandatory no-fault endorsement in 11 NYCRR 65-1.1 requires written proof of claim for health services no later than 45 days after the services are rendered (DFS Office of General Counsel opinion quoting the regulation).

Both systems are complicated enough to need their own guides.

What to do with this

Add a “fully insured / self-funded” field to insurance verification, and fill it from the ID card.
Set your filing alerts by payer and plan type. Use 120 days for New York fully insured commercial plans unless your contract gives more, 90 days for eMedNY, and each managed care plan’s contract.
Keep clearinghouse acceptance reports for every claim. They’re your proof of timely filing and of receipt for prompt pay.
Put a written out-of-network referral consent into your referral workflow.
Check your collection agency contract for the credit-reporting ban.

Marlow is a billing company based on Long Island, and these rules decide which claims we can still collect on. The free audit flags claims close to a filing deadline in your own 835s and AR aging.

Sources

General information, not advice on a specific claim, contract or legal question. Rules and rates change; check the linked sources for the current version.