New York emergency department billing services
Professional ER billing for emergency medicine groups in New York: MDM-based 99281-99285 levels, critical care time, modifier 25, payer enrollment and No Surprises Act claims, built on the New York payer rules verified below.
What changes an ER claim in New York.
Every New York rule on file, each linked to its primary source: state surprise-billing law, Medicaid ER policy, Medicaid managed care, the Blue plan and the Medicare contractor.
| Rule type | Date | What it says | Source |
|---|---|---|---|
| State surprise-billing law | Aug 2026 | FSL 605: plan pays OON emergency provider what it deems reasonable; patient owes in-network cost share. Either side may file with a state IDR entity that picks plan payment or provider fee (binding). From 26-Aug-2026 the IDRE has 45 business days after full information (was 30). | Source |
| Medicaid ER policy | Mar 2026 | NY Medicaid FFS: no copay on private practicing physician services, so do not collect a copay on the ER physician claim; the $3 copay applies to the ER visit itself only when non-urgent or non-emergency. | Source |
| Medicaid managed care | May 2026 | Fidelis Care FC.PP.005 (all products incl. Medicaid): prepayment review of professional ED E/M 99281-99285; algorithm and nurse review assign a maximum level per diagnosis and reduce higher-billed levels (no denials). Revised 13-May-2026. | Source |
| Blue plan | Apr 2026 | Highmark BCBS of WNY and Highmark Blue Shield of NENY: from 27-Apr-2026 professional ED claims coded 99284 or 99285 with a low-acuity, non-emergent presenting diagnosis (Mercer LANE) are automatically downcoded to 99283 under RP-037; EOP shows both codes. | Source |
| Medicare contractor | Dec 2021 | Medicare Part B professional claims in New York go to National Government Services (NGS), A/B MAC Jurisdiction K (JK). | Source |
How we bill New York ER visits.
The same four-step workflow we run for emergency medicine and hospitalist groups billing from their hospital system.
Hospital feed and registration
Demographics, insurance and the attending physician arrive from the hospital system daily. Gaps go back to registration as clarification requests, not guesses.
MDM levels and critical care minutes
ED visits 99281-99285 are coded on medical decision making only. Critical care is 99291 for 30 to 74 minutes and 99292 from 104 total minutes, on documented time.
Modifier 25 and enrollment check
A separately identifiable E/M on the day of a procedure carries modifier 25 with its own documentation. The rendering physician is checked against the payer roster before release.
Submission, remit and NSA/IDR
Professional claims go out with place of service 23. Out-of-network ER claims follow the No Surprises Act: in-network cost share only, open negotiation, then federal IDR.
FAQ: ER billing in New York.
Does New York have a state surprise billing law for ER care?
FSL 605: plan pays OON emergency provider what it deems reasonable; patient owes in-network cost share. Either side may file with a state IDR entity that picks plan payment or provider fee (binding). From 26-Aug-2026 the IDRE has 45 business days after full information (was 30).
What does New York Medicaid require for ED visits?
NY Medicaid FFS: no copay on private practicing physician services, so do not collect a copay on the ER physician claim; the $3 copay applies to the ER visit itself only when non-urgent or non-emergency.
How do New York Medicaid managed care plans handle ER claims?
Fidelis Care FC.PP.005 (all products incl. Medicaid): prepayment review of professional ED E/M 99281-99285; algorithm and nurse review assign a maximum level per diagnosis and reduce higher-billed levels (no denials). Revised 13-May-2026.
What is the New York Blue plan policy on ER claims?
Highmark BCBS of WNY and Highmark Blue Shield of NENY: from 27-Apr-2026 professional ED claims coded 99284 or 99285 with a low-acuity, non-emergent presenting diagnosis (Mercer LANE) are automatically downcoded to 99283 under RP-037; EOP shows both codes.
Which Medicare contractor processes New York ER professional claims?
Medicare Part B professional claims in New York go to National Government Services (NGS), A/B MAC Jurisdiction K (JK).
Nearby ER billing state guides.
Neighbouring state pages with their own verified ER payer rules.