MedicaidPrior AuthHigh impact
Prior Approval Changes Effective January 1, 2027
NY Medicaid·NY · Radiology, OB-GYN, Oncology +3 more·Provider Bulletin
Effective date
Jan 1, 2027
We identified it
Jun 30, 2026
Summary
New York State Medicaid is implementing federally-mandated prior authorization timeline changes effective January 1, 2027. Standard prior auth requests must now be processed within 7 days (previously 21 days), expedited requests within 72 hours, with up to 14-day extensions permitted. The policy also clarifies NYS Medicaid coverage for breast cancer screening, imaging, and testing services including mammography, tomosynthesis, ultrasound, MRI, and genetic testing at no cost to patients.
Action Required
By December 31, 2026: (1) Billing team must update prior authorization submission workflows to comply with new 7-day standard and 72-hour expedited timelines for NYS Medicaid FFS claims. (2) Configure billing system to track prior auth decision dates and flag requests exceeding the 7-day window or 14-day extension maximum. (3) Update provider and staff training materials to reflect that failure to submit requested documentation within the new timelines will result in PA denial. (4) Enroll practice in ePACES and eMedNY eXchange if not already enrolled to enable real-time prior authorization requests and eligibility verification, which will support meeting compressed timelines. (5) Billing team must ensure all breast cancer screening claims (CPT 77065, 77066, 77067, 77063) are processed with zero cost-sharing for eligible patients per NYS Breast Cancer Screening Law. (6) Update claim submission protocols to remove any outdated 21-day timeline references. Contact eMedNY at (800) 343-9000 with billing questions and OHIPMedPA@health.ny.gov for policy clarification.