New York State Medicaid Update - February 2026 Volume 42 - Number 2

In this issue …

New York State Medicaid Emergency Services Only Coverage

The purpose of this article is to remind providers of New York State (NYS) Medicaid policy when submitting claims for treating individuals with Emergency Services Only (ESO) Coverage Code "07". Such individuals are only eligible for treatment of an "emergency medical condition" as defined in federal regulation.

§1903(v) of the Social Security Act allows for Medicaid coverage for emergency services provided for the treatment of an emergency medical condition (including emergency labor and delivery) Federal regulation 42 Code of Federal Regulations (CFR) §440.255 defines emergency medical services as, "services required after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

  • placing the health of the patient in serious jeopardy;
  • serious impairment to bodily functions; or
  • serious dysfunction of any bodily organ or part."

NYS Medicaid will only cover emergency medical services provided for the treatment of an emergency medical condition that meets this definition at the time the medical service is provided. For drug-specific guidance, providers should refer to the Medicaid Fee-for-Service (FFS) Emergency Services Only Coverage document. Not all services that are medically necessary for the treatment of a medical condition are entitled to reimbursement under ESO coverage. The treating medical provider must reasonably determine that the emergency medical condition definition has been met. Emergency medical conditions do not include debilitating conditions (e.g., heart disease or other medical conditions requiring rehabilitation) resulting from the initial event which later requires ongoing regimented care.

Please note: Services may be medically necessary but may not meet this definition for coverage. Providers should refer to the Medicaid for the Treatment of an Emergency Medical Condition Fact Sheet, for additional information.

Indicating an Emergency Medical Condition on a Claim

When submitting a claim to NYS Medicaid for services provided to an individual with ESO coverage and indicating the service(s) is an emergency, as described in the bullets below, the medical provider who administered the treatment is attesting that the condition meets the federal definition of an emergency medical condition.

  • For claims submitted on the Medical Assistance Health Insurance Claim Form (eMedNY 150003), "YES" should be checked in Field 16A – "Emergency Related".
  • For Professional claims submitted electronically (837P), the Emergency Indicator field should indicate "Y-Yes".
  • For Institutional claims submitted electronically (837I), the Admission Type should be "1-Emergency".

Please note: Clinic/institutional claims will be payable if the attestation completed by the practitioner confirms that the services were provided for a medical condition that meets the federal definition of an emergency medical condition and the primary diagnosis code reported has been identified by NYS Medicaid as one that meets the federal definition.

Professional claims will be payable if the attestation completed by the practitioner confirms that the services were provided for a medical condition that meets the federal definition of an emergency medical condition and both the primary diagnosis code and procedure codes reported have been identified by NYS Medicaid as those that meet the federal definition.

Please note: As of 2013, a NYS Department of Health DOH-4471 form is no longer required to be submitted to authorize ESO coverage to an otherwise eligible individual. For additional information, providers should refer to the NYS Department of Health GIS 13 MA/09: Changes to Medicaid Coverage for the Treatment of an Emergency Medical Condition" web page.

NYS Medicaid providers are ultimately responsible for providing accurate and complete information on the claim so that a coverage determination may be made. The primary International Classification of Diseases, Tenth Revision (ICD-10) diagnosis should represent the most specific condition that reflects the emergency medical condition. NYS Medicaid payments, as always, are subject to post payment review.

If a claim is denied for edit "00547" - RECIPIENT INELIGIBLE FOR NON-EMERGENCY SERVICE DUE TO COVERAGE CODE and the provider affirms the primary ICD-10 diagnosis code reported on the claim accurately represents an emergency medical condition under the federal definition, the provider may email a request for a review of that diagnosis code to FFSMedicaidPolicy@health.ny.gov.

To verify if an individual has ESO coverage based on the reason response, providers can perform an eligibility request on electronic Provider Assisted Claim Entry System (ePACES) found under the eMedNY Tools Center on the eMedNY homepage (under the top menu). The Eligibility Response for these patients will return, "emergency services only".

Questions and Additional Information:

  • ESO coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
  • Questions regarding Medicaid eligibility should be directed to the Local District Support Unit at (518) 474-8887 (Upstate) and (212) 417-4500 (NYC).
  • Questions related to the billing process and on performing eligibility requests on ePACES should be directed to eMedNY Call Center at (800) 343-9000.

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Guidance For Dental Providers: New Requirements for Enteral and Parenteral Conscious Sedation Specialty and License Requirements for General Anesthesia Billing

Dentists with appropriate New York State Education Department (NYSED) certification have been able to request that specialty code "810" – conscious sedation be added to their New York State (NYS) Medicaid enrollment. However, to align with NYSED regulations and to more accurately adjudicate and process dental anesthesia claims, specialty code "810" has been end-dated and replaced with four new specialty codes as follows:

  • Specialty Code "122" – Dental Parenteral Conscious (Moderate) Sedation, 13 years of age and up
  • Specialty Code "123" – Dental Enteral Conscious (Moderate) Sedation, 13 years of age and up
  • Specialty Code "124" – Dental Parenteral Conscious (Moderate) Sedation, under 13 years of age
  • Specialty Code "125" - Dental Enteral Conscious (Moderate) Sedation, under 13 years of age

Effective February 13, 2026, dentists who are newly enrolling in the NYS Medicaid program will be able to add any of the above specialty codes to their provider enrollment file as long as the appropriate certification appears on their NYS professional license.

Currently enrolled dentists who have Specialty Code "810" (parenteral conscious sedation) listed on their NYS Medicaid provider enrollment file must update their enrollment file with the appropriate new specialty code(s), noted above, along with the required documentation by May 1, 2026. After that date, claims submitted by providers with specialty code "810" will be denied payment. To request the addition of the new dental conscious sedation specialty codes to their provider enrollment profile, providers should complete the New York State Department of Health Application for Enrollment as a Specialist (eMedNY-490301), and submit it via one of the following methods:

  1. By secure fax to the Bureau of Provider Enrollment at (518) 473-7251, Attn: Dental Specialty
  2. By United States Postal Service to:
    eMedNY
    P.O. Box 4610
    Rensselaer, NY 12144-4610

Providers must include a copy of the NYS professional license of the provider indicating the requested certification.

Allowable procedures codes when billing under each of the new specialty codes are as follows:

Specialty Code Description Allowable Procedure Codes
122 Dental Parenteral Conscious (Moderate) Sedation, 13 years of age and up D9239, D9243, D9246
123 Dental Enteral Conscious (Moderate) Sedation, 13 years of age and up D9245
124 Dental Parenteral Conscious (Moderate) Sedation, under 13 years of age D9239, D9243, D9246
125 Dental Enteral Conscious (Moderate) Sedation, under 13 years of age D9245

In addition, the NYS professional license of the provider must include a General Anesthesia designation to bill the two recently added Current Dental Terminology (CDT) codes:

CDT Code Description Certification Required
D9224 Administration of general anesthesia with advanced airway – first 15-minute increment, or any portion thereof. NYSED certificate in General Anesthesia.
D9225 Administration of general anesthesia with advanced airway – each subsequent 15-minute increment, or any portion thereof. NYSED certificate in General Anesthesia.

Questions and Additional Information:

  • Questions regarding adding the specialty codes to an enrollment file or any questions related to billing with these new specialty codes can be directed to the eMedNY Call Center at (800) 343-9000.
  • Medicaid Managed Care (MMC) requirements for documentation and/or questions related to billing an MMC Plan should be directed to the specific MMC Plan of the MMC enrollee receiving the service. MMC Plan contact information and plan directory can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.

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New York State Medicaid Enteral Nutrition Regulatory Amendment and Prior Authorization Updates

Effective February 11, 2026, Subdivision (g) of §505.5 of Title 18 of the Official Compilation of Codes, Rules and Regulations of the State of New York has been amended to:

  • Increase the defined benefit calorie limit for New York State (NYS) fee-for-service Medicaid members for oral-fed nutritional formula from 1,000 calories per day to 1,250 calories per day.
  • Include coverage for NYS Medicaid members previously approved for oral-fed supplementation who demonstrate the continued ability to maintain a body mass index (BMI) of 18.5 to 24.9 while receiving oral-fed supplemental nutrition. Nutritional needs required over the defined benefit shall be reviewed for medical necessity on a case-by-case basis.

Providers should refer to the Enteral Nutrition Defined Benefit Changes regulation posting.

In addition to the regulatory amendment described above, NYS Medicaid has implemented the following enteral nutrition prior authorization (PA) updates:

For additional guidance regarding NYS Medicaid enteral nutrition defined benefits and PA changes, providers should refer to the New York State Medicaid Program - Enteral Nutrition Regulatory Amendment and Prior Authorization Changes document.

Questions:

  • Questions related to this update should be directed to the Bureau of Medical Review at (800) 342-3005 or OHIPMEDPA@health.ny.gov.
  • Billing and claim questions should be directed to eMedNY at (800) 343-9000.

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New Listserv Available for New York State Medicaid Primary Care and Patient-Centered Medical Home Providers

The eMedNY Medicaid Primary Care LISTSERV® is a method for communicating with primary care providers and other New York State (NYS) Medicaid partners. This LISTSERV® is a supplement to the Medicaid Update and enables subscribers to instantly receive:

  • NYS Patient-Centered Medical Home (PCMH) program updates;
  • announcements about upcoming webinars and Medicaid primary care-related information;
  • notice of fee schedule updates; and
  • billing related notifications.

The eMedNY LISTSERV® is available free of charge and has no limitations on the number of individuals allowed to subscribe from a practice, business, or organization. Providers are encouraged to subscribe to as many categories as they feel are necessary, to ensure they receive the important eMedNY communications that may impact their practice and business processes. Please note: All eMedNY LISTSERV® communications are archived and available for viewing at a later time.

Subscribing to the eMedNY LISTSERV® is quick and easy. Providers can visit the eMedNY homepage, then select the "eMedNY LISTSERV®" button on the right side of the homepage. On the eMedNY "eMedNY LISTSERV®" web page, providers can check off all desired categories. Once categories have been selected, providers must enter their email address at the bottom of the web page, then select "submit".

Questions and Additional Information:

  • Questions regarding the eMedNY LISTSERV® should be directed to the eMedNY Call Center at (800) 343-9000.
  • Questions regarding NYS Medicaid primary care and/or NYS PCMH can be directed to PCMH@health.ny.gov.

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New York State Medicaid Evidence Based Benefit Review Advisory Committee Meeting on April 17, 2026

The New York State Medicaid Evidence Based Benefit Review Advisory Committee (EBBRAC) will convene a meeting on Friday, April 17, 2026, from 10 a.m. to 3:30 p.m. (ET) to review "Acupuncture for Treatment of Nonspecific Chronic Low Back Pain in Adults". The meeting will be held at The State University of New York, 116 East 55th Street, New York, NY 10022.

Public presentations are welcome; however, interested parties must notify the NYS Department of Health by Sunday, April 12, 2026, of their request to address the NYS Medicaid EBBRAC, in-person, during the public presentation period. Requests may be submitted to EBBRAC@health.ny.gov, with "EBBRAC Speaker Request" in the subject line. Additionally, interested parties must complete the Evidence Based Benefit Review Advisory Committee Public Presentation Registration Form.

The NYS Medicaid EBBRAC was established in 2015 pursuant to Chapter 57, Part B, §46-a of the Laws of 2015, as Social Services Law §365-d, to make recommendations to the NYS Department of Health regarding NYS Medicaid coverage of health technologies and services.

Additional Information

Providers should refer to The NYS Department of Health Medicaid "Evidence Based Benefit Review Advisory Committee (EBBRAC)" web page or email EBBRAC@health.ny.gov, for additional information regarding NYS Medicaid EBBRAC and upcoming meetings.

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NYRx, the New York State Medicaid Pharmacy Program: Prior Authorization Update

On October 3, 2025, the New York State (NYS) Medicaid Drug Utilization Review Board (DURB) recommended changes to NYRx, the NYS Medicaid Pharmacy program. The Commissioner of Health has reviewed the recommendations of the DURB and approved the following changes. Effective February 19, 2026, prior authorization (PA) requirements may change in the following Preferred Drug Program (PDP) drug classes:

  • Immunomodulators & Related Agents, Topical
  • Immunomodulators, Systemic
  • Leukotriene Modifiers

The following Drug Utilization Review (DUR) program clinical criteria requirements will be implemented:

  • PA will be required for patients utilizing a Dipeptidyl Peptidase-4 (DPP-4) Inhibitor and a Glucagon-like Peptide-1 (GLP-1) Receptor Agonist concurrently.
  • PA will be required for patients utilizing two or more Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) concurrently.
  • For patients initiating an antispasmodic skeletal muscle relaxant, PA will be required for a quantity exceeding a 14-day supply and up to one refill. The quantity and frequency limitations do not apply to skeletal muscle relaxants when used as spasmolytics.
  • Trial of two Proton Pump Inhibitors (PPIs) at maximally tolerated doses prior to the use of a Potassium Competitive Acid Blocker (PCAB). The recommendation does not apply to a diagnosis of Helicobacter pylori (H. Pylori).
  • Elevidys will be covered for male patients, four to five years of age, in compliance with all Food and Drug Administration (FDA) product safety labeling requirements.

For additional information about the DURB, providers should refer to the NYS Department of Health "Drug Utilization Review (DUR)" web page. For additional information regarding NYRx PA criteria, providers should refer to the NYRx, the Medicaid Pharmacy Program Preferred Drug List.

To review a list of preferred products that generally do not require a PA when prescribed according to FDA labeling (unless otherwise indicated), providers should refer to the NYRx Preferred Drug Quick List.

For a complete list of drugs covered by NYRx, providers should refer to the Medicaid Pharmacy List of Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page. Electronic PA requests are now accepted by NYRx via CoverMyMeds®. Consider this option as an effective and efficient way to request a PA. PA requests can also be submitted by phone at 1-877-309-9493 or by fax at 1-800-268-2990 to the NYRx Clinical Call Center, available 24 hours a day, seven days a week. For additional information, providers should contact NYRx Education and Outreach Center at NYRxEO@primetherapeutics.com.

For practitioner-administered drug Clinical Criteria Worksheets, prescribers and pharmacists should refer to the New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance.

Resources:

Questions and Additional Information:

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The Medicaid Update is a monthly publication of the New York State Department of Health.

Kathy Hochul
Governor
State of New York

James McDonald, M.D., M.P.H.
Acting Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs