Federal Community Engagement Requirements for New York State Medicaid Coverage

IMMEDIATE ACTIONS REQUIRED: (1) Billing team must implement coordination of benefits workflow for denture claims at FQHCs: Bill CDT codes D5110, D5120, D5211, D5212, D5213, D5214, D5225, D5226 to primary insurance first, then pro-rate the payment amount across visits needed (max 5 visits), subtract pro-rated amount from PPS rate per visit, and submit remainder to NYS Medicaid. Update billing system rules and staff training immediately. (2) Clinical labs must update billing to directly bill NYS Medicaid for HPV testing using CPT 87623, 87624, 87625, 87626 when collected in healthcare settings; coordinate with practitioners who continue billing E&M codes separately. (3) BY MARCH 1, 2026: Remove prior authorization requirement for CPT 71271 (lung cancer screening CT) from billing workflows for NYS Medicaid FFS; ensure no claims are delayed due to prior auth holds. Communicate to providers that screening should be administered without copayment. (4) BY JULY 1, 2026: Billing team must configure system to append modifiers P1, P2, or P3 (based on patient systemic disease status) to qualifying E&M '491' codes billed to OASAS clinics; apply 20% rate enhancement to line-level payment calculation. For medication management or psychiatric E&M, append HE (mental health) or HF (substance use disorder) modifiers instead. Update provider encounter templates and train staff on modifier selection. Failure to implement denture COB workflow will result in underpayment or claim denials; failure to remove prior auth for lung cancer screening may delay medically necessary screening.