Reminder: Unlicensed Interns, Residents and Foreign Physicians in Training Programs are Authorized Prescribers for New York State Medicaid Members

IMMEDIATE ACTIONS (effective now per policy): 1) Billing Team: For all FQHC denture claims involving NYS Medicaid members with third-party insurance, implement pro-rated coordination of benefits calculations. Calculate primary insurance payment per visit by dividing total primary payment by number of denture fabrication visits (up to 5). Subtract pro-rated primary amount from PPS rate per visit to determine NYS Medicaid secondary payment. Update billing system logic and staff training on the provided calculation methodology. Failure to pro-rate will result in overpayment or underpayment and potential recovery actions. 2) Laboratory/Clinical Staff: Implement HPV testing billing for CPT codes 87623, 87624, 87625, 87626 when specimens are collected in healthcare settings (provider-collected or patient self-collected). Clinical labs may bill directly to NYS Medicaid. Do not bill separate specimen collection fees. Providers may continue billing E&M codes if documentation supports the visit level. 3) Billing Team: Remove prior authorization requirements for CPT 71271 (low-dose chest CT) for lung cancer screening effective March 1, 2026. Update billing software and preauthorization workflows. Ensure screenings are processed without copay. 4) Behavioral Health Providers: Prepare for July 1, 2026 (FFS) or November 1, 2026 (MMC) implementation of 20% rate enhancement for physical health E&M services in OASAS and developmental disability/TBI waiver settings. Identify qualifying CPT codes that group to Medical Visit APG (E/M 491) and prepare to append P1, P2, or P3 modifiers (health status) or HE/HF modifiers (mental health/substance use disorder) per service type. Contact NYS Medicaid for specific rate tables and CPT code lists before effective dates.