CurrentEmblemHealthPolicy N/A

Payment Integrity Administrative Policy: Medicaid State Directed Payments and Benchmark Rate Adjustments

Governs how EmblemHealth implements New York State Department of Health (NYSDOH) adjustments to facility-specific Safety Net/UPL add-ons and nursing home benchmark rates, and how those updated Medicaid fee schedules are loaded and applied to claims for contracted practitioners and facilities.

Policy Summary

PayerEmblemHealth

PolicyMedicaid State Directed Payments and Benchmark Rate Adjustments

Policy CodePolicy N/A

Change TypeTitle clarifiednew policy created (10/14/2025)

Effective Date

Next Review DateApr 1, 2026

Key ActionLoad, test, and make updated NYSDOH Medicaid fee schedules available and apply retroactive adjustments within 90 days of receipt.

SourceLink

POLICY UPDATE CHANGES

Policy title updated for clarity; formerly entitled Medicaid Benchmark Rate Adjustments.

New policy specific to Medicaid facility-specific benchmark rate adjustments only (noting initial creation).

90 daystimeframe to apply updates

NYstate

Safety Net/UPL & nursing homeadjustment types

Automaticretroactive handling

Application and Timing

Application and timing

Operational rules for application of updated Medicaid fee schedules:

EmblemHealth updates its systems based upon fee schedules approved by the New York State Department of Health (NYSDOH) and uses those updated fee schedules to calculate payments to contracted practitioners and facilities.

This policy applies specifically to NYSDOH adjustments to facility-specific Safety Net/UPL add-ons and nursing home benchmark rates only.

ALL of the following

EmblemHealth will load, test, and make the newest Medicaid fee schedule rates available to pay claims within 90 days of receipt.
EmblemHealth will automatically make necessary retroactive adjustments to previously paid claims within the same 90-day processing window.

Policy Summary

PayerEmblemHealth

PolicyMedicaid State Directed Payments and Benchmark Rate Adjustments

Policy CodePolicy N/A

Change TypeTitle clarifiednew policy created (10/14/2025)

Effective Date

Next Review DateApr 1, 2026

Key ActionLoad, test, and make updated NYSDOH Medicaid fee schedules available and apply retroactive adjustments within 90 days of receipt.

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.

Fee Schedules and Effective Processing

Fee schedule codesmixed

No codes listed

Fee schedule effective processing window

Processing windowUpdated fee schedules are loaded, tested, made available for payment, and necessary retroactive adjustments to previously paid claims are applied within 90 days of receipt.

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

ScopeApplies to Medicaid fee schedules approved by the New York State Department of Health (NYSDOH).

Operational steps summarizedLoad new schedule, test implementation, publish rates for claims processing, and perform automatic retroactive adjustments where required — all within the 90-day window.

Administrative Payment-Rate Updates

Billing Rule

Administrative payment-rate updates — no PA required

EmblemHealth will administratively load, test, and make updated NYSDOH Medicaid fee schedules available for payment and will automatically apply retroactive adjustments to previously paid claims; no prior authorization or clinical authorization is required as part of this administrative payment-rate update process.

Updated fee schedules are loaded, tested, and made available within 90 days of receipt.
Claims received after the load date are paid using the updated fee schedule.
Automatic retroactive adjustments are applied to previously paid claims.

NYSDOH Facility-Specific Medicaid Adjustments

NYSDOH facility-specific Medicaid adjustments

Defined adjustmentsNYSDOH facility-specific Medicaid adjustments include Safety Net/UPL add-ons and nursing home benchmark rates.

Policy applicabilityThis policy is applicable only to NYSDOH adjustments to facility-specific Safety Net/UPL add-ons and nursing home benchmark rates.

Use in payment calculationsEmblemHealth updates systems based on these NYSDOH-approved fee schedules and uses them to calculate payments to contracted practitioners and facilities.

Retroactive applicationNecessary retroactive adjustments to previously paid claims for these facility-specific adjustments are made automatically when schedules are implemented.