MedicaidPrior AuthHigh impact
Increase in Reimbursement for Article 28 Clinic Providers Delivering Mental Health Services
NY Medicaid·NY · Radiology, Oncology, General Practice +3 more·Claims & Billing
Effective date
Jan 1, 2027
We identified it
Jun 30, 2026
Summary
This policy contains multiple updates effective January 1, 2027: (1) NYS Medicaid prior authorization timelines are changing from 21 days to 7 days for standard requests and 72 hours for expedited requests, with a potential 14-day extension for additional information; (2) NYS Medicaid now covers breast cancer screening, diagnostic imaging, and testing with no patient cost-sharing, including mammograms, ultrasounds, MRI, and biopsies per specific clinical guidelines. The policy also encourages provider enrollment in ePACES/eMedNY eXchange for electronic claim submission and real-time prior auth requests.
Action Required
REQUIREMENTS:
Before January 1, 2027:
- Billing and prior auth teams must update internal workflows to comply with new NYS Medicaid prior authorization timelines: standard PA requests must be processed within 7 calendar days (vs. previous 21 days) with potential 14-day extension for additional information; expedited PA requests must be adjudicated within 72 hours. Update PA tracking systems to flag requests nearing the 7-day deadline.
- Providers must enroll in ePACES and eMedNY eXchange systems (or verify existing enrollment) to enable real-time claim submission, eligibility verification, and prior auth requests. Obtain ePACES enrollment instructions from eMedNY Provider Manuals web page.
- Billing team must update system rules and billing software to recognize new breast cancer screening CPT codes (77065, 77066, 77067, 77063) as covered services with zero patient cost-sharing under NYS Medicaid FFS and Managed Care programs. Remove any prior authorization requirements or patient cost-sharing edits for these codes when billed by qualified providers.
- Coding staff must update encounter forms and templates to reflect breast cancer screening coverage criteria, including documentation requirements for medical necessity (family history, prior cancer history, dense breasts, BRCA status, age-appropriate screening).
- Update claim submission checklists to ensure all prior auth requests include complete documentation per applicable provider manual; incomplete submissions will result in PA denial under the new 7-day timeline.
- Immediately enroll providers in ePACES if not already enrolled; same credentials work for both ePACES and eXchange. Contact eMedNY at (800) 343-9000 for billing questions or enrollment support.
CONSEQUENCES OF INACTION:
- Prior authorization requests not submitted with complete documentation will be denied within 7 days.
- Claims for breast cancer screening services billed with patient cost-sharing or without proper medical necessity documentation may be denied or subject to recovery.
- Inability to submit prior auth requests electronically through eMedNY eXchange will result in delays and potential missed timelines.