MedicaidPrior AuthHigh impact
New York State Medicaid Reminder on Documentation and Records Retention Requirements
NY Medicaid·NY · Radiology, Oncology, General Practice·Provider Bulletin
Effective date
Jan 1, 2027
We identified it
Jun 30, 2026
Summary
New York State Medicaid is implementing federal CMS prior authorization timeline requirements effective January 1, 2027: standard PA requests must be adjudicated within 7 days (extendable to 14 days with additional documentation needed), and expedited PA requests within 72 hours. Additionally, NYS Medicaid now covers breast cancer screening, diagnostic imaging, and related services with no patient cost-sharing, including mammography (all ages with appropriate clinical criteria), tomosynthesis, ultrasound, MRI, and genetic testing.
Action Required
PRIOR AUTHORIZATION WORKFLOW: By December 1, 2026, billing team must update internal tracking systems and provider education to reflect new PA timelines—standard requests now require 7-day adjudication (vs. previous 21-day standard) with up to 14-day extension only if additional documentation is requested. Implement expedited PA process (72-hour turnaround) with clear criteria for emergent cases. Ensure all PA submissions include complete necessary documentation to avoid automatic denials. Contact eMedNY at (800) 343-9000 for billing questions. BREAST CANCER SCREENING COVERAGE: Effective immediately, billing team must recognize that NYS Medicaid FFS and MMC now cover breast cancer screening and diagnostic services with zero cost-sharing to patients. Update billing system to: (1) bill CPT 77065, 77066, and 77067 for diagnostic and screening mammography without patient cost-sharing requirements; (2) recognize CPT 77063 (tomosynthesis with mammogram) as covered when medically necessary; (3) ensure breast ultrasound and MRI claims for qualifying patients (dense breasts, high-risk individuals, prior abnormalities, etc.) process without copay/coinsurance; (4) allow genetic testing for high-risk individuals per clinical guidelines. Update claim submission procedures to ensure no denial codes related to patient cost-sharing are applied to these services. Train billing staff that transgender and gender-diverse screening criteria per Cleveland Clinic and ACR guidelines must be honored per clinician orders.