MedicaidPrior AuthHigh impact
New York State Medicaid Prescriber Education Program: Free 1.5 Hour Continuing Education on Antibiotic Stewardship
NY Medicaid·NY · Radiology, Oncology, OB-GYN +3 more·Provider Bulletin
Effective date
Jan 1, 2027
We identified it
Jun 30, 2026
Summary
New York State Medicaid has updated prior authorization (PA) timelines effective January 1, 2027, reducing standard PA processing from 21 days to 7 days, with expedited requests now requiring 72-hour determination. The policy also expands breast cancer screening coverage (including mammography, tomosynthesis, ultrasound, and MRI) with no patient cost-sharing and provides specific billing codes and clinical guidelines for covered services.
Action Required
REQUIREMENTS:
By December 31, 2026: Billing team must update internal PA tracking systems and submission workflows to comply with new 7-day standard timeline (previously 21 days) and 72-hour expedited timeline for New York State Medicaid fee-for-service claims. Update PA denial protocols to reflect automatic denials if requested documentation is not submitted within the extended 14-day timeframe.
By January 1, 2027: Billing team must implement breast cancer screening coverage changes in billing software, ensuring CPT codes 77065, 77066, 77067, and 77063 are billed with zero patient cost-sharing for NYS Medicaid members. Verify that claims systems do not apply copays, coinsurance, or deductibles to these codes.
Immediately: Billing team must enroll in ePACES and eMedNY eXchange if not already enrolled to enable real-time PA submission and eligibility verification, which will facilitate compliance with shortened PA timelines. Follow enrollment instructions in eMedNY ePACES Enrollment document.
Before January 1, 2027: Providers and billing staff must review updated NYS Medicaid provider manuals (available on eMedNY Provider Manuals web page) for revised PA submission criteria. Train staff on new expedited PA request conversion protocol (if a request does not meet expedited criteria, it will automatically convert to standard request).
Ongoing: Flag all NYS Medicaid PA denials that result from missed documentation deadlines—these will now occur within the 14-day window instead of previous timelines. Route documentation requests to providers with clear deadline notices to prevent claim denials.
Consequences of inaction: Prior authorization requests will be denied if documentation is not received within stated timelines, claims will be rejected if submitted with patient cost-sharing for covered breast cancer screening codes, and inability to meet 7-day PA processing may result in operational penalties or coverage disputes.