[New York] April 2026 Provider Newsletter

MULTIPLE EFFECTIVE DATES - PRIORITIZED ACTION REQUIRED: **IMMEDIATE (By April 1, 2026):** - Billing team and providers must review all policy updates listed in newsletter and identify applicable changes to your practice - Front desk: Ensure providers understand new "Physician access and appointment availability standards" for Commercial plans (effective April 1, 2026) - Billing team: Review new Availity Essentials features for out-of-network providers and update workflows accordingly - Compliance team: Review "Using AI responsibly to protect patient privacy" guidance across all plan types and ensure practices are compliant **BY MAY 1, 2026:** - Billing team must update fee schedules in billing system to reflect PT and OT fee increase for Commercial products (effective May 1, 2026) - Billing team must implement prior authorization and step therapy updates for Medicaid (effective May 1, 2026) - Update encounter forms and billing software for PT/OT billing to reflect new rates **BY JUNE 1, 2026:** - Billing team must update specialty pharmacy precertification requirements in billing system per expansion effective June 1, 2026 for Medicare Advantage - Compliance team: Complete provider data attestation reminders due June 30, 2026 for all plan types **BY JULY 1, 2026:** - Billing team must implement reimbursement policy updates effective July 1, 2026: * New policy for Treatment Rooms with Office E/M Services for Commercial * New policy for Drugs and Devices Requiring Procedures at facilities for Commercial * Genetic Testing "Once per Lifetime" policy for Medicaid and Medicare Advantage * New reimbursement policy for Treatment Rooms for Medicare Advantage - Update billing software validation rules to enforce new policies - Update encounter templates to capture required clinical documentation per new guidelines - Front desk: Implement "After hours for primary care physicians" requirement for Medicaid (effective July 1, 2026) - Billing team must review Carelon Medical Benefits Management clinical guideline updates (effective June 14, 2026) and communicate changes to providers **CONSEQUENCES:** Non-compliance will result in claim denials, payment delays, and potential contract violations. Billing software must be updated before effective dates or claims will be incorrectly processed.