Cardiology Billing Services in New York

New York Medicaid cardiology runs through fee-for-service and through Medicaid managed care plans. For New York City, the Department of Health's September 2026 mainstream managed care enrollment report lists Healthfirst, Fidelis Care (Centene), MetroPlus Health Plan, HIP of Greater New York (EmblemHealth), Molina Healthcare of New York, UnitedHealthcare and Anthem Blue Cross and Blue Shield, among others. Affinity Health Plan is not on that list: Molina closed on its acquisition of substantially all of Affinity's assets on 25 October 2021, so a payer master still carrying the two as separate plans is out of date. Each plan contracts its own provider network and handles prior authorization requests itself or through a contracted utilization review agent, so whether 93458 (left heart catheterization), 92928 (PCI with stent), nuclear cardiology (78451, 78452) or cardiac MRI (75557) needs approval is checked against the member's plan before the procedure is booked. Health and Recovery Plans (HARPs) manage care for adults with significant behavioral health needs, integrating their physical health, mental health and substance use services. Managed Long Term Care runs three lines: MLTC Partial Capitation covers community-based long-term care and ancillary services such as home care, while Medicaid Advantage Plus and PACE integrate primary, acute and long-term care. Fee-for-service claims must be initially submitted within 90 days of service (eMedNY's General Billing guidelines, version 2025-1, read 6 November 2026); for a Medicaid managed care plan, Insurance Law 3224-a(g)(1) sets 120 days unless the provider contract sets a different period, which may not be under 90 days. We build per-MCO cardiology workflows including portal-based auth submission, peer-to-peer scheduling for adverse determinations, and per-plan documentation expectations referenced to ACC/AHA appropriate use criteria.

Two of the Blue plans in New York's commercial cardiology mix are Anthem and Excellus. Anthem Blue Cross and Blue Shield is the former Empire BlueCross BlueShield: on 1 January 2024, Empire BlueCross BlueShield became Anthem Blue Cross and Blue Shield and Empire BlueCross became Anthem Blue Cross, across commercial, Medicaid and Medicare business. Excellus BlueCross BlueShield, headquartered in Rochester, serves upstate New York through regions based in Syracuse, Elmira, Rochester and Utica. Carelon Medical Benefits Management (formerly AIM Specialty Health) reviews the services in its cardiology, radiology and genetic testing programs for the Anthem commercial members who take part in them; Anthem's 2023 notice offered the programs to self-funded (ASO) groups not already in them as an add-on. Anthem's New York provider notices moved coronary artery calcium CT (75571) to prior authorization at AIM under its Imaging of the Heart guideline from 1 November 2021, and added cardiac resynchronization therapy and peripheral revascularization to Carelon's cardiology program in August and October 2023, with Medicare Advantage, Medicaid, Medicare and Federal Employee Program members excluded from that expansion. An outpatient procedure entered in Anthem's Interactive Care Reviewer that Carelon administers is referred to Carelon, and the complete code lists sit on Carelon's program pages, so each code is checked against the list in force on the service date. Stress echocardiography is 93350/93351 — CMS's NCCI Policy Manual, Chapter 11, pairs the stress echo contrast add-on 93352 with those two codes. For Excellus and every other commercial plan, the reviewer and the code list are confirmed per plan and product before the procedure is booked.

New York is a No-Fault auto insurance state. Insurance Law Section 5103 requires an owner's auto liability policy to provide first-party benefits, and Section 5102 counts necessary medical, hospital and x-ray expenses among them, so cardiology care for a motor vehicle accident patient is billed to the No-Fault insurer on a separate rail from the patient's commercial or Medicaid coverage. Section 5108 caps those charges at the fee schedules the chair of the Workers' Compensation Board sets for industrial accidents, unless the insurer or an arbitrator finds that unusual procedures or unique circumstances justify more. The clocks are in the mandatory personal injury protection endorsement, 11 NYCRR 65-1.1: written notice of the accident as soon as reasonably practicable and no later than 30 days after it, and written proof of claim for health service expenses no later than 45 days after the services are rendered, each unless clear and reasonable justification for the delay is shown. The insurer may require the patient to submit to medical examination by physicians it selects, as often as it reasonably requires, and may ask for an examination under oath, an authorization to obtain medical records and other information it needs to decide the amount due. A disagreement over the claim can go to arbitration under procedures the Superintendent of Financial Services promulgates or approves. We manage No-Fault cardiology billing as a distinct workflow — separate fee schedules, separate document filing, and a separate dispute process when the auto insurer denies medical necessity.

New York Insurance Law Section 3224-a sets the clock, and the first thing to establish is whether it reaches the plan at all. By its own opening it governs health care claims under contracts issued pursuant to Article 32 and Articles 42, 43 and 47 of the Insurance Law and Article 44 of the Public Health Law, and it binds insurers and the corporations and organizations licensed or certified under those articles. A self-funded employer plan paying its own claims is not one of them, and neither is Medicare or a Medicare Advantage plan. On a downstate cardiology panel carrying real MA and self-funded volume, that plan-type check comes before the prompt-pay letter.

Where the section does apply, subsection (a) requires payment within thirty days of a claim transmitted electronically and forty-five days of one submitted by other means, such as paper or facsimile. Two exceptions sit in the same sentence: where the obligation to pay is not reasonably clear, and where there is a reasonable basis, supported by specific information available for review by the superintendent, that the claim was submitted fraudulently. Note what the trigger is not — the statute does not condition the clock on a "clean claim." Where the obligation is unclear because of a good-faith dispute, subsection (b) requires the payer to pay any undisputed portion and, within thirty calendar days, to say in writing whether the claim is denied or partially approved, which payment it is not obligated to make and why, and to request all additional information it needs; once that information or an appeal arrives the subsection (a) clock runs again, and any additional payment found due must be made within fifteen days of the determination.

Subsection (c)(1) sets interest on an overdue amount at the greater of twelve percent per annum or the rate the New York Commissioner of Taxation and Finance sets for corporate taxes under paragraph one of subsection (e) of Section 1096 of the Tax Law, computed from the date the payment was required to be made. There is no federal funds rate anywhere in the section. Interest below two dollars need not be paid, which is why interest is worth pursuing on cath lab and device claims and not worth the letter on a tracing.

Two New York deadlines run the other way, against the practice, and both belong on a cardiology A/R calendar. Subsection (g)(1) makes a claim valid and enforceable only if it is initially submitted within one hundred twenty days after the date of service, unless the contract gives the provider more favourable terms; Medicaid and Child Health Plus contracts may set a different period, but not less than ninety days. Subsection (h) then lets a participating provider ask for reconsideration of a claim denied solely as untimely, where the lapse followed an unusual occurrence and the provider has a pattern of filing on time — but the payer may reduce that claim by up to twenty-five percent, and the subsection does not apply at all to a claim submitted three hundred sixty-five days after the date of service, which may be denied in full.

We track every claim against the thirty-day clock, flag stalled payments at day twenty-five, and file DFS prompt-pay complaints when payers default. There is a structural reason to file rather than to phone. Subsection (c)(2) shields a payer from the civil penalty where the superintendent finds violations through the superintendent's own investigation, examination, audit or inquiry and the payer processed at least ninety-eight percent of a calendar year's claims in compliance — but that paragraph "shall not apply to violations of this section determined by the superintendent resulting from individual complaints submitted to the superintendent by health care providers or policyholders." A documented provider complaint sits outside the safe harbour; a phone call does not. (Statute text read at the New York State Senate's published consolidated laws, the revision in effect 19 September 2025, on 17 September 2026.)

93458 (coronary angiography with left heart catheterization) and 93452 (left heart catheterization with ventriculography) are cardiac catheterization codes — CMS's NCCI Policy Manual, Chapter 11, revision date 1 January 2025, groups 93451-93461 that way — and each plan's prior-authorization list is checked for them before the case is booked; for Anthem Blue Cross and Blue Shield (formerly Empire) commercial members, that check includes Carelon's cardiology program list. 93306 (complete TTE with Doppler) needs the medical necessity documented in the record. 93015 is the global cardiovascular stress test code, and it is not the code you split with -26 and -TC. The stress test family runs 93015-93018 — the range the same chapter calls the traditional exercise stress test — and which code in that range is correct turns on what the practice actually furnished in that setting. Settle it against the payer's fee schedule for that place of service before the first claim goes out, not with a component modifier on the global code afterwards. 93000 (ECG with interpretation and report) has a specific bundling rule: CMS's NCCI Policy Manual, Chapter 11, states that a cardiovascular stress test includes the ECG strips at 93000-93010 and that those "shall not be reported separately," and likewise bars them where they relate to delivery of an anesthetic agent. Code against that edit rather than against a blanket assumption that a tracing disappears into any same-day E/M. 93295 (remote ICD interrogation) is one of the defibrillator interrogation codes the same chapter bars from separate reporting with a cardioversion (92960, 92961); its coverage and frequency limits are confirmed per plan. 92928 (PCI) is reported with a vessel modifier — LD, LC, RC, LM or RI, the five listed in Medicare contractor WPS's PCI billing article (A57479, revised 1 January 2026). 93798 (cardiac rehab with monitoring) requires per-session documentation, and the Medicare limit is the one to know: 42 CFR 410.49 caps cardiac rehabilitation at two 1-hour sessions per day, up to 36 sessions over up to 36 weeks, with an option for a further 36 sessions over an extended period if the Medicare Administrative Contractor approves (intensive cardiac rehabilitation runs to 72 sessions, up to 6 a day, over up to 18 weeks). Regulation text read on 17 September 2026. Commercial and Medicaid managed care plans' limits, Anthem Blue Cross and Blue Shield (formerly Empire) included, are confirmed per plan. 78452 (nuclear myocardial perfusion imaging, multiple studies) is checked against the plan's imaging prior-authorization list in force on the service date.

Downstate health systems include NYU Langone, Mount Sinai, NewYork-Presbyterian (with its Columbia and Weill Cornell campuses), Northwell Health and Maimonides Medical Center in Brooklyn; upstate, they include Rochester Regional Health and University of Rochester Medicine in Rochester, Kaleida Health and Catholic Health in Buffalo, SUNY Upstate Medical University in Syracuse, and Albany Medical Center. Whether a cardiology practice bills under a system's payer contracts or under contracts of its own decides where the billing work sits: reconciling against the system-level fee schedule, or running payer-by-payer fee schedule checks and denial follow-up.