New York State Medicaid Evidence Based Benefit Review Advisory Committee to Review AI-Enabled Devices for Diabetic Retinopathy Screening

REQUIREMENTS: By December 31, 2026: Billing team must prepare systems and workflows for the new NYS Medicaid prior authorization timelines. Specifically: (1) Update billing software to process standard PA requests within 7 days and expedited PA requests within 72 hours; (2) Configure system to track PA submission dates and enforce the 14-day extension window for additional information requests; (3) Ensure claims are denied if requested documentation is not submitted within required timeframes; (4) Enroll in ePACES and eMedNY eXchange (if not already enrolled) to enable real-time PA submission and eligibility verification—enrollment is required for eXchange inbox activation. Immediately: Update billing workflows and encounter templates to ensure all breast cancer screening and diagnostic imaging claims (CPT 77065, 77066, 77067, 77063) are billed without cost-sharing for covered populations. Providers should document medical necessity per clinical guidelines. Update internal protocols to reflect that breast ultrasound and MRI are covered for qualifying scenarios (dense breasts, abnormalities on mammography, high-risk populations, family history of BRCA1/BRCA2). For any questions on coverage criteria, PA guidelines, or policy requirements, direct inquiries to NYS Department of Health Office of Health Insurance Programs at (800) 342-3005 or OHIPMedPA@health.ny.gov. Failure to comply with new PA timelines will result in claim denials; failure to remove cost-sharing from covered services will result in compliance issues.