Billing for Services Provided to the Office of Mental Health Residential Treatment Facility Residents

REQUIREMENTS: By January 1, 2027: Billing team must update all systems and workflows to reflect new prior authorization timelines. Specifically: - Update PA submission tracking systems to enforce 7-day standard processing window (from receipt date with complete documentation) and 14-day maximum extension when additional information is requested - Configure expedited PA workflow for 72-hour processing for emergent cases, with automatic conversion to standard requests if expedited criteria are not met - Ensure providers are enrolled in ePACES and eMedNY eXchange for real-time PA submission and claims tracking; enrollment is REQUIRED for eXchange inbox activation - Update internal PA policies and staff training to reflect that failure to submit requested documentation within CMS timelines will result in PA denial - Communicate new timelines to all clinical and administrative staff who submit prior authorization requests Immediately (now): Billing team must implement breast cancer screening and diagnostic coverage updates in billing system: - Configure CPT codes 77065, 77066, 77067, and 77063 to process as covered services with $0 patient cost-sharing for NYS Medicaid FFS and Medicaid Managed Care members - Update clinical documentation requirements to support medical necessity for breast imaging services (e.g., dense breasts, prior history, family history, transgender/gender-diverse patients on GAHT ≥5 years, high-risk genetic mutations) - Train billing and front-desk staff that mammography baseline services (age 35-39) and routine annual screening (age 40+) require no prior authorization; diagnostic and supplemental imaging requires clinical documentation supporting medical necessity - Add to claim submission workflow: breast ultrasound and MRI require documented clinical indication (abnormal mammogram, dense breasts, high lifetime risk ≥20%, BRCA mutation, prior chest radiation <30 years, hereditary cancer syndromes, or pregnancy/breastfeeding status) - Note: Breast tomosynthesis (CPT 77063) must be billed with 2D digital mammography to receive payment Consequences: Claims submitted without proper PA authorization after January 1, 2027 may be denied if not adjudicated within new timelines. Breast cancer screening claims billed without appropriate coverage code configuration will be denied or improperly cost-shared.