MedicaidAdministrativeHigh impact
New York State Medicaid Coverage of Nucleic Acid Amplification Testing for the Purpose of Bacterial Vaginosis and Sexually Transmitted Infection Diagnosis and Treatment
NY Medicaid·NY · Pharmacy, Wound Care, Endocrinology·Provider Bulletin
Effective date
Jul 29, 2026
We identified it
Sep 18, 2026
Summary
New York State Medicaid updated four major policy manuals effective July 29, 2026: (1) Telehealth Policy Manual with new CPT codes 99445 and 99470, updated RPM procedure codes, and revised billing grids; (2) NYRx Compound Policy clarifying reimbursement criteria and excluded ingredients for compounded medications; (3) Patient Centered Medical Home Billing Guidance with updated payment tables and quality metrics; and (4) Hyperbaric Oxygen Therapy coverage policy with specific conditions and patient criteria. Billing teams must review all four manuals to identify applicable service changes and update billing systems accordingly.
Action Required
By July 29, 2026: (1) Billing team must access the NYS Department of Health Telehealth Policy Manual and update billing software to recognize new CPT codes 99445 and 99470, reorganize RPM procedure code tables per guidance, and apply updated rate information for CPT 99407. (2) Pharmacy billing staff must review NYRx Compound Policy guidelines and update pharmacy claim submission systems to reject compounded prescriptions containing excluded ingredients (anticonvulsants, NSAIDs, skeletal muscle relaxants, tricyclic antidepressants, antifungal combinations, soaks/irrigations, non-FDA-approved ingredients). Stop using Submission Clarification Code 08 for excluded ingredients or indications—claims will be denied. (3) All billing staff must download Patient Centered Medical Home Billing Guidance and update PCMH payment tables for fee-for-service, MMC, CHPlus, and Adirondack program; communicate new quality metrics requirements to providers. (4) Update claims review processes for Hyperbaric Oxygen Therapy (HBOT) to verify: patient meets one of four primary conditions (acute carbon monoxide intoxication, decompression illness, gas embolism, gas gangrene) OR meets adjunctive therapy criteria with Wagner grade III+ diabetic wound and 30+ days of failed standard therapy; HBOT provided in Article 28 hospital-based setting by physician/NP/PA. All teams: contact NYS Department of Health with policy questions at listed phone/email addresses. Failure to comply will result in claim denials.