CurrentEmblemHealthPolicy N/A

Annual Fee Schedule Updates (CMS and Medicaid)

Governs how EmblemHealth updates and applies CMS and New York Medicaid fee schedules to calculate payments to contracted practitioners and facilities; affects providers paid under Medicare-based and NY Medicaid fee schedules.

Policy Summary

PayerEmblemHealth

PolicyAnnual Fee Schedule Updates (CMS and Medicaid)

Policy CodePolicy N/A

Change TypeClarification and link added

Effective Date

Next Review Date

Key ActionLoad, test, and make newest fee schedules available to pay claims within 60 days of receipt; claims received after the load date are paid using the updated schedule with no retroactive adjustments.

SourceLink

POLICY UPDATE CHANGES

Added link to EmblemHealth Medicaid Benchmark Rate Adjustments Payment Integrity Policy.

Updated 'Policy Statement' for clarity and removed content specific to CMS fee schedule updates only.

Added clarification regarding reimbursement of CMS Status C Codes.

Transferred policy content to individual company-branded template.

60 daystimeframe to load, test, and make new fee schedules available to pay claims

CMS Status C Codesaddresses reimbursement approach for temporary HCPCS Level II codes

NYSDOHsource of Medicaid fee schedules used

Payment Integrity policy linkseparate guidance for Medicaid facility-specific benchmark rate adjustments

Fee Schedule Application Rules

Fee schedule application rules

Operational criteria for loading and applying updated fee schedules from CMS and NYSDOH.

Load, test, and make the newest fee schedule available to pay claims within 60 days of receipt.

Once the fee schedule is loaded, claims received after the load date are paid using the updated fee schedule, if applicable.

No retroactive adjustments will be made based on the new fee schedule for claims submitted prior to the initial 60-day time frame.

New York State Department of Health (NYSDOH) facility-specific benchmark rate adjustments are excluded from this general load/apply rule and are governed by a separate Payment Integrity Policy.

For CMS Status C Codes (temporary HCPCS Level II codes), EmblemHealth follows Medicare Administrative Contractor (MAC)-established payment amounts; CMS does not set the fees for these codes, and pricing may use documentation such as operative reports.

Policy Summary

PayerEmblemHealth

PolicyAnnual Fee Schedule Updates (CMS and Medicaid)

Policy CodePolicy N/A

Change TypeClarification and link added

Effective Date

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding Notes and Timelines

CMS Status C CodesHCPCS

C codes

Temporary HCPCS Level II codes for new technology devices, drugs, biologicals, and radiopharmaceuticals with transitional pass-through status under OPPS.

Fee schedule load window

Load and testing windowFee schedules received from CMS or NYSDOH are loaded, tested, and made available to pay claims within 60 days of receipt.

Effect on claims received after load dateClaims received after the fee schedule load date are paid using the updated fee schedule, if applicable.

No retroactive adjustmentsNo retroactive adjustments will be made to claims submitted prior to the initial 60-day time frame based on the new fee schedule.

ScopeApplies to fee schedules from CMS (Medicare) and Medicaid fee schedules released by NYSDOH for practitioners and contracts that follow these schedules.

ExclusionsExcludes NYSDOH facility-specific benchmark rate adjustments, which are governed by a separate Payment Integrity Policy.

Provider Expectations and Reimbursement Approach

Billing Rule

Application timing for updated fee schedules

Providers should expect that EmblemHealth loads and tests updated fee schedules (CMS and Medicaid) within 60 days of receipt. Once a new fee schedule is loaded and available, claims received after the load date will be paid using the updated fee schedule when applicable. No retroactive adjustments will be made to claims submitted prior to the initial 60-day loading/testing timeframe.

Applies to fee schedules received from CMS and NYSDOH Medicaid.
No retroactive payment changes for claims submitted before the fee schedule was loaded and available.

Billing Rule

Reimbursement approach for CMS Status C Codes

For CMS Status C (temporary HCPCS Level II) codes, EmblemHealth follows Medicare guidance and typically adopts payment amounts established by the Medicare Administrative Contractor (MAC). C codes are initially priced at the MAC’s discretion (often using supporting documentation such as operative reports); EmblemHealth aligns reimbursement for these C codes with the MAC-established amounts. This approach applies to Medicare contracts and to Commercial contracts that explicitly follow Medicare payment methodology.

C codes are temporary HCPCS II codes for new technology with transitional pass-through status under OPPS.
EmblemHealth’s reimbursement is guided by CMS policies and MAC-established payment amounts.

Key Definitions

CMS Status C Codes — definition

DefinitionCMS Status C Codes are temporary HCPCS Level II codes created by CMS to report new technology devices, drugs, biologicals, and radiopharmaceuticals with transitional pass-through status under the Medicare Hospital Outpatient Prospective Payment System (OPPS).

Initial pricing authorityThese codes are initially priced at the discretion of the Medicare contractor (MAC).

EmblemHealth reimbursement approachEmblemHealth follows Medicare Administrative Contractor (MAC) established payment amounts for C codes and uses supporting documentation (e.g., operative reports) in pricing determinations.

CMS fee-settingCMS does not set the fees for Status C Codes; MACs establish initial pricing.

Medicaid fee schedules (NYSDOH)

DefinitionMedicaid fee schedules are the fee schedules released by the New York State Department of Health (NYSDOH) used to calculate payments to practitioners reimbursed under the Medicaid fee schedule.

Application timingEmblemHealth loads, tests, and makes the newest NYSDOH Medicaid fee schedule available to pay claims within 60 days of receipt.

Effect on claimsClaims received after the Medicaid fee schedule load date are paid using the updated schedule; no retroactive adjustments will be made for claims submitted prior to the initial 60-day time frame.

ExclusionsNYSDOH facility-specific benchmark rate adjustments are excluded from this general load/apply rule and are addressed in a separate Payment Integrity Policy.