MedicaidCoverageHigh impact
NYRx Compound Policy and Proper Billing Practices
NY Medicaid·NY · Pharmacy, General Practice, Family Medicine +1 more·Pharmacy
Effective date
Jul 29, 2026
We identified it
Sep 18, 2026
Summary
NYS Medicaid updated three policies effective July 29, 2026: (1) Telehealth Policy Manual with new CPT codes 99445/99470, updated RPM procedures, teledentistry billing grids, and revised coverage restrictions; (2) NYRx Compound Policy clarifying that compounded products require compendia support, documented clinical need, and prohibiting use of SCC '08' for excluded ingredients/indications; (3) Patient Centered Medical Home Billing Guidance with updated payment tables and quality reporting requirements. The compound policy explicitly warns that misusing SCC '08' violates NYS Medicaid policy and will be monitored.
Action Required
By July 29, 2026: (1) Billing team must update billing system to recognize new telehealth CPT codes 99445 and 99470 and ensure proper claim submission per updated RPM procedure code table; update teledentistry billing grid logic to reflect revised site/location categories and new RDH collaborative practice model. (2) Pharmacy billing staff must immediately audit all compounded prescription claims to ensure: final compounded products are compendia-supported for prescribed route and indication; documented clinical need exists that cannot be met by FDA-approved alternatives; SCC '08' is NEVER used for excluded ingredients (anticonvulsants, NSAIDs, skeletal muscle relaxants, tricyclic antidepressants, combinations of 2+ antifungals, soaks/irrigations) or excluded indications; sensitivities/contraindications to dyes, preservatives, fillers are documented on prescriptions. (3) PCMH-enrolled providers must update practice information in HCS and implement required quality metrics reporting. (4) Providers must stop reconstituting commercially available products for compounding claims. Non-compliance with compound policy will result in claim denials and potential monitoring by NYS Department of Health. Direct questions to: eMedNY Call Center (800) 343-9000 for telehealth/general billing; NYRx Pharmacy Policy Unit (518) 486-3209 or NYRx@health.ny.gov for compound policy.