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NYS Medicaid Breast Cancer Selective Program Reimbursement Policy
Effective date
Apr 1, 2026
Identified
Jun 20, 2026
Summary
Healthfirst's NYS Medicaid Breast Cancer Selective Program policy (PO-RE-168v1) requires prior authorization for all breast cancer surgical procedures under the program, and those procedures must be performed at NYS-approved facilities. Services rendered at restricted facilities are not eligible for reimbursement, and authorization requests listing a restricted facility will be denied. The policy applies only when a qualifying diagnosis code from Appendix A is linked to a qualifying procedure code, and Appendix A states the Medicaid breast cancer service exclusion is effective April 1, 2025.
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What to do
Action · 7 steps
01Already effective 2026-04-01: Billing team: obtain prior authorization for all breast cancer surgical procedures under the NYS Medicaid Breast Cancer Selective Program, with requests submitted in accordance with Healthfirst utilization management guidelines.
02Billing team: list the specific facility where the surgery will be performed on the authorization request, and make sure it matches the facility where services are rendered.
03Billing team: confirm the facility is an approved NYS Breast Cancer Selective Program facility before services are rendered, since authorization requests listing a restricted facility will be denied and services at restricted facilities are not eligible for reimbursement.
04Billing team: link a qualifying diagnosis code from Appendix A to a qualifying procedure code listed in the policy, since claims without that linkage are processed under standard reimbursement guidelines.
05Providers: be appropriately credentialed and privileged at these facilities to be eligible for reimbursement.
06Billing team: ensure accurate billing reflecting the correct site of service and provider credentials.
07Exceptions are not permitted unless explicitly authorized by NYS Medicaid guidance.
Codes mentioned
C50.011C50.012C50.019C50.021C50.022C50.029C50.111C50.112C50.119C50.121C50.122C50.129C50.211C50.212C50.219C50.221C50.222C50.229C50.311C50.312C50.319C50.321C50.322C50.329C50.411C50.412C50.419C50.421C50.422C50.429C50.511C50.512C50.519C50.521C50.522C50.529C50.611C50.612C50.619C50.621C50.622C50.629C50.811C50.812C50.819C50.821C50.822C50.829C50.911C50.912C50.919C50.921C50.922C50.929D05.00D05.01D05.02D05.10D05.11D05.12D05.80D05.81D05.82D05.90D05.91D05.92Z85.319120191251912619301193021930319304193051930619307
Original notice
NYS Medicaid Breast Cancer Selective Program Reimbursement Policy
hfproviders.org · Always check the source before changing claims.
Related changes
See all Healthfirst changes →Related policy hubs
Healthfirst policiesNY policy changesGeneral SurgeryOncologyOB-GYNCode C50.011Code C50.012Code C50.019Code C50.021Code C50.022Code C50.029Code C50.111Code C50.112Code C50.119Code C50.121Code C50.122Code C50.129Code C50.211Code C50.212Code C50.219Code C50.221Code C50.222Code C50.229Code C50.311Code C50.312Code C50.319Code C50.321Code C50.322Code C50.329Code C50.411Code C50.412Code C50.419Code C50.421Code C50.422Code C50.429Code C50.511Code C50.512Code C50.519Code C50.521Code C50.522Code C50.529Code C50.611Code C50.612Code C50.619Code C50.621Code C50.622Code C50.629Code C50.811Code C50.812Code C50.819Code C50.821Code C50.822Code C50.829Code C50.911Code C50.912Code C50.919Code C50.921Code C50.922Code C50.929Code D05.00Code D05.01Code D05.02Code D05.10Code D05.11Code D05.12Code D05.80Code D05.81Code D05.82Code D05.90Code D05.91Code D05.92Code Z85.3Code 19120Code 19125Code 19126Code 19301Code 19302Code 19303Code 19304Code 19305Code 19306Code 19307