MedicaidPrior AuthHigh impact
New PA Timelines:
NY Medicaid·NY · Radiology, Oncology, OB-GYN +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 (PA) timeline changes effective January 1, 2027, reducing standard PA processing from 21 days to 7 days, with expedited requests determined within 72 hours. The policy also clarifies NYS Medicaid coverage for breast cancer screening and diagnostic services (mammography, ultrasound, MRI, biopsy) with no cost-sharing to patients, including specific guidelines for transgender and gender-diverse individuals.
Action Required
By December 31, 2026: (1) Billing team must update prior authorization submission workflows to comply with new 7-day standard PA timeline and 72-hour expedited PA timeline for NYS Medicaid fee-for-service claims. (2) Update claim denial protocols to reflect automatic PA denial if required documentation is not submitted within the new timeframes or if expedited requests are converted to standard requests. (3) Providers must enroll in ePACES and eMedNY eXchange if not already enrolled to enable real-time PA submission and real-time claim processing to meet new timelines. (4) Update billing system templates and encounter forms to distinguish between standard and expedited PA requests, with expedited reserved for emergent cases only. (5) For breast cancer screening claims: ensure billing team uses correct CPT codes (77065, 77066, 77067 for diagnostic mammography; 77063 for tomosynthesis with mammogram) and applies zero cost-sharing edits. (6) Train billing staff and providers on new requirements. Failure to submit PAs within the new timeline or use incorrect codes will result in claim denials. Contact eMedNY at (800) 343-9000 for technical support on system updates.