NYRx Pharmacy Drug Coverage: Claims Processing Enhancements and Reminders
AI Summary
New York State Medicaid has updated prior authorization requirements for pharmacy claims, prohibiting third-party entities from submitting PA requests and clarifying that only prescribers or their authorized agents may request prior authorizations. The policy also provides updated coverage criteria for wireless capsule endoscopy procedures.
Action Required
Immediately: Review current prior authorization workflows to ensure only prescribers or their authorized agents (employees with access to patient medical records) are submitting PA requests. Stop any third-party PA submission arrangements. For wireless capsule endoscopy, verify procedures meet new coverage criteria before billing CPT codes 91110 and 91111. Document medical necessity and retain records for minimum 6 years.
Affected Billing Codes
Plan Types
Medicaid
States
NY
Specialties
gastroenterology, family-medicine, internal-medicine