MedicaidReimbursementHigh impact
Project TEACH Announces Fall 2026 Mental Health Trainings, Webinars, and Resources for New York State Providers
NY Medicaid·NY · Dentistry, Infectious Disease, Pulmonology +2 more·Specialty Services
We identified it
Sep 17, 2026
Summary
New York State Medicaid has implemented multiple billing policy updates effective immediately and throughout 2026, including: (1) coordination of benefits rules for denture services at FQHCs with third-party insurance requiring pro-rated calculations across multiple visits; (2) clarification that HPV testing is covered with specific CPT codes billable by clinical labs; (3) removal of prior authorization requirements for lung cancer screening CT (CPT 71271) effective March 1, 2026; and (4) 20% rate enhancements for physical health E&M services in addiction treatment clinics effective July 1, 2026 with required modifier appending (P1/P2/P3 or HE/HF).
Action Required
IMMEDIATE ACTIONS REQUIRED: (1) Billing team must immediately implement denture billing changes: for FQHCs billing CDT codes D5110, D5120, D5211-D5214, D5225, D5226 to NYS Medicaid members with third-party insurance, bill primary insurance first, then calculate pro-rated secondary payment by dividing primary insurance payment by number of visits (typically 5) and subtract from PPS rate per visit. Update billing system logic and create reference guide with pro-ration calculation steps. (2) Clinical lab billing staff must activate billing for HPV testing using CPT codes 87623, 87624, 87625, 87626 to NYS Medicaid FFS (clinical labs bill directly, not practitioners). Ensure E&M services are billed separately when appropriate. Update lab billing system and reference materials. (3) By March 1, 2026: Billing team must remove prior authorization requirement for CPT 71271 (low-dose lung cancer screening CT) in the billing system for NYS Medicaid FFS claims; ensure screenings are processed without copayment. Update prior auth workflow rules. (4) By July 1, 2026: For providers billing OASAS-certified addiction clinics, billing team must configure system to automatically append modifier P1, P2, or P3 to qualifying E&M codes that group to Medical Visit APG (E/M 491) to receive 20% rate enhancement; do NOT append these modifiers to medication management or psychiatric E&M services (use HE or HF modifiers instead). Update encounter forms and billing software. Claims submitted without correct modifiers will receive standard rates instead of enhanced rates. Contact eMedNY (800-343-9000) or dentalpolicy@health.ny.gov for denture/lab questions, FFSMedicaidPolicy@health.ny.gov for coverage questions.