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Restricted Breast Cancer Surgery Facilities
Effective date
Apr 1, 2026
Identified
Jul 17, 2026
Summary
Effective April 1, 2026, New York Medicaid and HARP will only cover breast cancer surgery (mastectomy and lumpectomy) at high-volume facilities performing 30+ procedures annually. Claims and preauthorization requests from low-volume facilities will be denied. Patients must be directed to high-volume providers. Diagnostic/excisional biopsies and post-surgical care remain unrestricted.
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What to do
Action · 7 steps
01Before April 1, 2026.
02Billing team must verify your facility's breast surgery volume on the NYSDOH website to confirm high-volume or low-volume status.
03If low-volume facility: Implement workflow to identify all Medicaid/HARP mastectomy and lumpectomy cases (CPT 19301-19312) and redirect patients to high-volume providers in their area before scheduling.
04Update preauthorization and billing system rules to automatically flag and deny claims for CPT 19301-19312 from this facility for Medicaid/HARP members.
05Brief clinical staff and front desk to inform patients of facility restrictions and provide referral list of high-volume providers.
06If high-volume facility: No action required for coverage eligibility, but confirm high-volume status and maintain documentation.
07Consequence: Claims for breast cancer surgery submitted by low-volume facilities will be denied and subject to recoupment by EmblemHealth.
Codes mentioned
193011930219303193041930519306193071930819309193101931119312
Original notice
Restricted Breast Cancer Surgery Facilities
emblemhealth.com · Always check the source before changing claims.