MedicaidPrior AuthHigh impact
New York State Medicaid Coverage of Basivertebral Nerve Ablation
NY Medicaid·NY · Radiology, OB-GYN, Family Medicine +2 more·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 prior auth requests must be processed within 7 days (extendable to 14 days for additional information), and expedited requests within 72 hours. This supersedes the previous 21-day timeframe and requires providers to submit complete documentation to avoid automatic denials. The policy also includes updated coverage guidelines for breast cancer screening services with specific CPT codes for mammography and tomosynthesis.
Action Required
By December 31, 2026: Billing team must implement the following changes to align with new NYS Medicaid prior auth timelines: (1) Update billing system workflows to track 7-day standard PA processing deadlines and 72-hour expedited PA deadlines, with automatic alerts if decisions are not rendered within these timeframes. (2) Revise prior auth submission procedures to ensure ALL necessary documentation is included with initial submissions, as incomplete submissions will trigger the 14-day extension clock and incomplete information after 14 days will result in automatic denial. (3) Enroll practice in ePACES and eMedNY eXchange to enable electronic real-time prior auth submission (required for eXchange access). (4) For breast cancer screening claims, ensure billing software correctly maps mammography services to CPT codes 77065 (one breast), 77066 (both breasts), 77067 (screening both breasts), and 77063 (tomosynthesis with mammogram), ensuring no cost-sharing is billed to NYS Medicaid patients. (5) Train billing and clinical staff on new submission requirements and denial prevention. Failure to comply will result in claim denials and processing delays. Contact OHIPMedPA@health.ny.gov for policy questions or eMedNY at (800) 343-9000 for billing questions.