MedicaidBilling CodesHigh impact
NYRx, the Medicaid Pharmacy Program: Prior Authorization Update
NY Medicaid·NY · Dentistry, Pharmacy, OB-GYN +4 more·Pharmacy
Effective date
Jan 1, 2026
We identified it
Sep 17, 2026
Summary
NYS Medicaid issued multiple policy updates effective immediately and on future dates: (1) denture billing at FQHCs now requires primary insurance billing first with pro-rated coordination of benefits calculations; (2) HPV testing coverage clarified with specific CPT codes billable by clinical labs; (3) prior authorization requirement removed for lung cancer screening CPT 71271 effective March 1, 2026; (4) 20% rate enhancement for physical health E/M services in OASAS clinics effective July 1, 2026 with required modifiers.
Action Required
IMMEDIATE ACTIONS: (1) Billing team must update claim submission workflows for denture services (CDT codes D5110, D5120, D5211, D5212, D5213, D5214, D5225, D5226) at FQHCs with third-party insurance: bill primary insurance first, calculate pro-rated reimbursement per visit (primary insurance payment divided by number of visits), then submit secondary claim to NYS Medicaid for difference up to PPS rate per visit for maximum five visits. Update billing software to enforce coordination of benefits calculations and document pro-ration methodology for audit purposes. (2) Clinical labs must be configured to bill CPT 87623, 87624, 87625, 87626 directly to NYS Medicaid for HPV testing without requiring provider billing intermediaries. (3) By March 1, 2026: Remove prior authorization requirement from billing system for CPT 71271 (lung cancer screening CT thorax). Update prior auth rules in billing software to eliminate PA requirement for this code. (4) By July 1, 2026: Configure billing system to apply 20% rate enhancement to E/M service line items in OASAS-certified clinics when codes group to Medical Visit APG (E/M 491). Implement modifier requirement: billing staff must append P1, P2, or P3 modifiers (based on patient systemic disease status) to qualifying E/M claims; append HE or HF modifiers instead for medication management/psychiatric E/M services. Train providers and billers on modifier selection criteria. Update encounter forms and EMR templates with modifier guidance. Claims submitted without appropriate modifiers may process at standard rates rather than enhanced rates. Contact eMedNY (800-343-9000) for billing questions or Office of Health Insurance Programs (518-473-2160) for policy clarification.