MedicaidPrior AuthHigh impact
New York State Medicaid Coverage of Breast Cancer Screening, Imaging, and Testing for Management and Treatment
NY Medicaid·NY · Radiology, Oncology, OB-GYN +3 more·Specialty Services
Effective date
Jan 1, 2027
We identified it
Jun 30, 2026
Summary
New York State Medicaid is implementing federal CMS prior authorization timeline changes effective January 1, 2027, reducing standard PA processing from 21 days to 7 days (with up to 14-day extension if additional info needed) and establishing 72-hour expedited PA timelines. Additionally, NYS Medicaid now provides comprehensive coverage for breast cancer screening, diagnostic imaging (mammography, ultrasound, MRI), and genetic testing with no patient cost-sharing, including services for transgender and gender-diverse individuals per updated clinical guidelines.
Action Required
IMMEDIATE AND BY JANUARY 1, 2027: (1) Billing team must immediately review and document all current breast cancer screening, imaging, and testing procedures being billed to NYS Medicaid FFS and MMC plans to ensure alignment with covered services (CPT 77065, 77066, 77067, 77063 for mammography/tomosynthesis; breast ultrasound and MRI when medically necessary per guidelines). (2) Update billing software and prior authorization submission processes to reflect new PA timelines: standard requests must be adjudicated within 7 days (with provision for 14-day extension if additional documentation requested), and expedited requests within 72 hours. (3) Before January 1, 2027: Enroll in ePACES and eMedNY eXchange if not already enrolled to enable real-time eligibility verification, claim submission, and prior auth requests. (4) Update all encounter forms and clinical documentation templates to capture required medical necessity criteria for breast ultrasound (dense breasts, abnormalities found, symptomatic presentation, high-risk status, etc.) and breast MRI (lifetime risk ≥20%, BRCA1/BRCA2 status, prior chest radiation before age 30, genetic syndromes). (5) Train providers on new coverage guidelines including screening recommendations for transgender females on GAHT ≥5 years and transgender males without chest surgery (age ≥40). (6) Communicate to patients that breast cancer screening services now have ZERO patient cost-sharing under NYS Medicaid. (7) Establish internal PA tracking to ensure compliance with new 7-day/72-hour timelines; failure to submit requested information within extended timeframes will result in PA denial. Contact OHIPMedPA@health.ny.gov or (800) 342-3005 with coverage/policy questions; (800) 343-9000 for billing questions.