Attention: Billing for Dentures at a Federally Qualified Health Center Receiving a Prospective Payment System Rate when the New York State Medicaid Member has Third-Party Insurance

Effective immediately, Federally Qualified Health Centers (FQHCs) who receive a Prospective Payment System (PPS) rate for the delivery of denture services rendered to New York State (NYS) Medicaid fee-for-service (FFS) members with third-party insurance should first bill the Current Dental Terminology (CDT) codes "D5110", "D5120", "D5211", "D5212", "D5213", "D5214", "D5225", and "D5226" to the primary/commercial insurer of the NYS Medicaid member. Commercial carriers make one payment upon delivery of prostheses, which may result in underpayment relative to the expected NYS Medicaid threshold payment multiplied by the visits needed for fabrication and delivery.

To ensure proper Coordination of Benefits and NYS Medicaid payment up to the PPS rate per visit, the amount of the final payment from the primary insurance should be pro-rated based on the number of visits needed to complete the denture(s). The NYS Medicaid reimbursement amount will then be calculated by the FQHC PPS rate minus the pro-rated payment amount from the primary insurance carrier per visit up to five visits. If the payment from the primary insurance equals or exceeds the total payment for five visits with a PPS rate, then there will be no additional NYS Medicaid payment.

Example: At a PPS rate of $250.00 per threshold visit, a full upper denture takes five visits to complete and deliver to the patient. The claim is submitted to the primary insurance carrier on the date the denture was delivered for a total reimbursement amount of $900.00. The FQHC then divides the amount paid by the primary payor ($900.00) by the number of visits needed for completion of the denture (five visits) which amounts to $180.00 per visit. Since this amount is less than the FQHC threshold rate of $250.00, the prorated amount ($180.00) is subtracted from the FQHC PPS threshold rate for each visit and the claim(s) are then submitted to NYS Medicaid for secondary reimbursement at $70.00 per threshold visit, for a total NYS Medicaid reimbursement rate of $350.00. Providers should refer to the table below for a breakdown.

Questions and Additional Information

NYS Medicaid FFS 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 dentalpolicy@health.ny.gov.

New York State Medicaid Coverage of Human Papillomavirus Testing

This article provides clarification for New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) coverage of human papillomavirus (HPV) testing. NYS Medicaid covers HPV testing, including provider-collected or patient self-collected specimens, when collected in a health care setting. The most appropriate HPV collection method for an individual should be a shared decision of the patient and their practitioner. There is not a separate reimbursement for specimen collection. NYS Medicaid-enrolled clinical laboratories performing the testing can bill NYS Medicaid directly for reimbursement for the testing performed. Practitioners may continue to bill for an Evaluation and Management (E&M) service for an encounter in which an HPV test is ordered when all required elements for that specific E&M code are met.

Please note: Self-collection is not recommended for high-risk/immunocompromised patients, as these individuals require both HPV and cytology testing, and cytology cannot be performed on self-collected vaginal specimens.

HPV lab testing, which includes practitioner-collected or patient self-collected specimens in a health care setting, may be billed by a clinical laboratory using the following Current Procedural Terminology (CPT) Codes:

Questions and Additional Information:

• NYS Medicaid FFS 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.
• NYS Medicaid FFS billing/claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• MMC enrollment, reimbursement, billing, and/or documentation requirement questions should be directed to the specific MMC Plan of the MMC enrollee. MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.
• Additional laboratory information and billing guidance is available in the eMedNY New York State Medicaid Program Fee-for-Service Laboratory Procedure Codes and Coverage Guidelines Manual.

Reminder: Removal of New York State Medicaid Prior Approval Requirements for Lung Cancer Screening

New York State (NYS) Medicaid aims to remove barriers to cancer screening. This article is a reminder that effective March 1, 2026, for NYS Medicaid fee-for-service (FFS), Current Procedural Terminology (CPT) code "71271" (CT thorax, low dose, without contrast) used for low-dose computed tomography lung cancer screening was removed from prior approval requirements. Coverage criteria remains consistent with the U.S. Preventive Services Task Force Grade B recommendation, and the screening should be administered without copayment. Medicaid Managed Care (MMC) Plans that continue to require prior approval for this screening should evaluate their lung cancer screening utilization and consider removal of this requirement.

Questions and Additional Information:

• NYS Medicaid FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• NYS Medicaid FFS 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.
• MMC reimbursement, billing, and/or documentation requirement questions should be directed to the MMC Plan of the enrollee.
• MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers – Managed Care Information document.

Rate Increases for Certain Services Delivered in Outpatient Settings certified by the Office of Mental Health, Office of Addiction Services and Supports and Office of People with Developmental Disabilities

Effective July 1, 2026, for New York State (NYS) Medicaid fee for service (FFS), and effective November 1, 2026, for Medicaid Managed Care (MMC) Plans, enhanced reimbursement will be provided for some physical health services delivered in the below behavioral health settings and for all services delivered by behavioral health providers in those settings that treat individuals eligible for or enrolled in the Office for People With Developmental Disabilities (OPWDD) waiver and enrolled in the traumatic brain injury (TBI) waiver. Physical health services referenced here include preventive screening, chronic disease monitoring and management, and diagnosing and treating newly identified and acute health problems.

Initiative 1: Increase Reimbursement by 20 Percent for Physical Health Services Delivered in Office of Addiction Services and Supports Outpatient Clinics

Office of Addiction Services and Supports (OASAS)-certified Article 32 addiction medicine clinics are positioned to deliver whole-person care. These clinics are required to employ physicians, many of whom have the qualifications to oversee the implementation of services including preventive screening and chronic disease management. The existing relationships make them idea opportunities for the integration of physical health services directly into addiction treatment. These physicians should have established referral networks in place to ensure specialized follow up, evaluation and treatment as needed. Opioid Treatment Programs (OTPs) are already required to provide an annual physical, creating a natural opportunity to identify and treat unmet health needs. By enhancing rates for physical health services in OASAS clinics (including OTPs), New York can expand access to preventive and routine medical care for individuals with substance use disorders.

Effective July 1, 2026, a 20 percent rate enhancement will be applied to specific CPT codes billed as an Evaluation and Management (E&M) service in OASAS-certified clinics. The 20 percent enhancement will apply across all OASAS outpatient rate codes to the line-level payment calculation and will only apply when an E&M procedure code groups within the APG software to a Medical Visit APG (E&M "491"), which are outpatient E&M visits where a patient receives direct general or specialty physical medical treatment, evaluation, or diagnosis from a practitioner without a dominant significant procedure being performed. This enhancement will not apply to E&Ms that represent medication management or psychiatric evaluation services. Providers will be required to append one of the following three modifiers to the line with the qualifying E&M "491": P1 (for healthy patients), P2 (for patients with minor systemic disease), or P3 (for patients with severe systemic disease). When an E&M code represents medication management or psychiatric evaluation services, providers shall not append the P1, P2, or P3 modifier, but instead append HE modifier (mental health service) or HF modifier (substance use disorder service) as appropriate.

Initiative 2: Increase Reimbursement for Select Physical Health Services by 20 Percent Delivered in an Article 31 Mental Health Outpatient Treatment and Rehabilitative Services (MHOTRS) Clinics

OMH-certified Article 31 MHOTRS clinics are authorized to deliver health monitoring services to the individuals they serve. Enhanced reimbursement for structured physical health services within these clinics can have a meaningful impact on individuals living with or at risk for chronic physical health conditions. Providing routine, basic physical health services in Article 31 settings to identify, monitor and manage these conditions can improve health outcomes and quality of life for individuals with serious mental illness. Providers in Article 31 settings should have established referral networks in place to ensure specialized follow up, evaluation and treatment as needed.

Effective July 1, 2026, a 20 percent rate enhancement will be applied to specific CPT codes billed in Article 31 MHOTRS clinics utilizing APG rate codes. The enhanced base rate applied in the line-level payment calculation will only apply when one of the CPT codes in the bundled service is billed in conjunction with an OMH MHOTRS APG rate code. The services targeted in this initiative include tobacco cessation and education, metabolic monitoring, and diabetes management. The following CPT codes are eligible for the 20 percent rate enhancement when billed in conjunction with a MHOTRS APG rate code: "99401", "99402", "99403", "99404", "99411", "99412", "99473", "99474", "G0447", "99406", "99407", "99382", "99383", "99384", "99385", "99386", "99387", "99392", "99393", "99394", "99395", "99396", and "99397".

Initiative 3: Increase Reimbursement by 20 Percent for Physical Health Services Delivered in Article 16 Clinics

Individuals with intellectual and developmental disabilities (I/DD) often experience complex medical needs that require ongoing monitoring and coordinated care. Article 16 clinics certified by the OPWDD are well-positioned to address these needs, given their specialized staffing and familiarity with the health care needs of this population. Enhancing rates for targeted physical health services can support early identification and management of high-risk conditions, reduce preventable health complications, reduce avoidable healthcare expenditures, and promote better long-term outcomes. Providers in Article 16 setting should have established referral networks in place to ensure specialized follow up, evaluation and treatment as needed.

Effective July 1, 2026, a 20 percent rate enhancement will be applied to specific CPT codes billed by OPWDD clinics using APG rate codes. The enhanced base rate applied in the line-level payment calculation will only apply when a specific physical health CPT code is billed in conjunction with an Article 16 outpatient clinic rate code. The following CPT codes are eligible for the 20 percent rate enhancement for a person who is determined eligible for OPWDD services (indicated by Restriction Exception (RE) code "95" being on file for the individual served) and when billed in conjunction with an OPWDD outpatient rate code: "97802", "97803", "97804", "G0270", "G0271", "97110", "97140", "97530", "92526", "97150", "97161", "97162", "97163", "97164", "92610", "90792", "98960", "G0108", "98961", "98962", "G0109", "96156", "99401", "99402", "99403", "99404", "99411", "99412", "96158", "95851", "96159", "96164", "96165", "96167", "96168", "96170", "96171", "97039", "97116", and "97799". The 20 percent enhancement will also apply when an OPWDD outpatient rate code is billed with a CPT code that groups to one of the following APG codes: "524", "525", "529", "532", "536", "827", "828", "005", "674", and "675".

Initiative 4: Increase Reimbursement by 20 Percent for all Services Delivered in an Article 31 Clinic to Individuals Enrolled in or Eligible for OPWDD Waiver Services and Individuals Enrolled in the TBI Waiver

Serving individuals with intellectual and/or development disabilities or brain injuries often requires more time, care, and expertise. Individuals with an I/DD and/or a TBI are often underserved due to various factors, including lack of referrals, systematic barriers, and stigma, among others. This initiative seeks to establish an increased rate for Article 31 clinic providers who serve the I/DD and TBI populations.

Effective July 1, 2026, a 20 percent rate enhancement will be applied to all services billed by OMH-certified MHOTRS clinics using APG rate codes. The enhancement for services delivered in an Article 31 MHOTRS clinic will apply to all procedures coded on the claim. The claim must include the U1 and U5 modifier combination in that order appended to any claim line. Providers should only append the U1 and U5 modifier combination when the individual has RE code "95" (eligible for OPWDD waiver services) and/or RE code "81" (enrolled in the TBI waiver) as reflected in MEVS. Only one enhancement will be applied when both RE codes are present.

Initiative 5: Increase Reimbursement by 50 Percent for Services Delivered in an Article 32 Clinic to Individuals Enrolled in or Eligible for OPWDD Waiver Services and/or to Individuals Enrolled in the TBI Waiver

Serving individuals with I/DD or brain injuries often requires more time, care, and expertise. Individuals with an I/DD and/or a TBI are often underserved due to various factors, including lack of referrals, systematic barriers, and stigma, among others. This initiative seeks to establish an increased rate for Article 32 clinic providers who serve the I/DD and TBI populations.

Effective July 1, 2026, a 50 percent rate enhancement will be applied to all services billed by OASAS-certified clinics using APG rate codes when the U1 and U5 modifier combination. The enhancement for services delivered in an Article 32 clinic will apply to all eligible procedures coded on the claim. The claim must include the U1 and U5 modifier combination in that order appended to any claim line. Providers should only append the U1 and U5 modifier combination when the individual has RE code "95" (eligible for OPWDD waiver services) and/or RE code "81" (enrolled in the TBI waiver) as reflected in MEVS. Only one enhancement will be applied when both RE codes are present.

Questions and Additional Information:

• Questions should be directed to integratedcaremailbox@health.ny.gov, with the subject line "Population Health Initiatives".
• For OASAS billing guidance, providers should refer to the NYS Department of Health "APG and Px-Based Weights History and APG Fee Schedules" web page.
• For OMH billing guidance, providers should refer to the following resources:
  • NYS Office of Mental Health 14 NYCRR Part 599 Mental Health Outpatient Treatment and Rehabilitative Services Medicaid Billing and Fiscal Guidance
  • NYS Office of Mental Health "Medicaid Reimbursement Rates" web page
• NYS Medicaid FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• NYS Medicaid FFS medical 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.

New York State Medicaid Evidence Based Benefit Review Advisory Committee Meeting on November 12, 2026

The New York State Medicaid Evidence Based Benefit Review Advisory Committee (EBBRAC) will meet November 12, 2026, to review "Heartflow FFRCT Analysis for Noninvasive Identification of Coronary Artery Disease." The meeting will run from 10 a.m. to 3:30 p.m. Eastern time at the State University of New York, 116 E. 55th St., New York.

Members of the public are welcome to make presentations but must notify the New York State (NYS) Department of Health by November 8, 2026, of their request to address the committee in person. Speaker requests should be sent by email to EBBRAC@health.ny.gov with "EBBRAC Speaker Request" in the subject line. Presenters must also complete the Evidence Based Benefit Review Advisory Committee Public Presentation Registration Form (PDF).

This will be the third EBBRAC meeting of 2026. At its last meeting on July 23, 2026, the committee reviewed "AI Devices for Autonomous Screening for Diabetic Retinopathy." Materials and reports from the July meeting can be found on the NYS Department of Health "Evidence Based Benefit Review Advisory Committee (EBBRAC )" web page.

EBBRAC was established in 2015 under Chapter 57, Part B, § 46-a of the Laws of 2015 (Social Services Law § 365-d) to advise the NYS Department of Health on state Medicaid coverage of health technologies and services.

For more information regarding the committee and upcoming meetings, providers can visit the NYS Department of Health "Evidence Based Benefit Review Advisory Committee (EBBRAC)" web page or email EBBRAC@health.ny.gov.

Project TEACH Announces Fall 2026 Mental Health Trainings, Webinars, and Resources for New York State Providers

Project TEACH (Parent and Infant/Child/Adolescent Psychiatry Access Program), funded by the New York State (NYS) Office of Mental Health (OMH), has announced its Fall 2026 lineup of live, in-person, and virtual training opportunities. These evidence-based programs are designed to support NYS clinicians in assessing, treating, and managing mild-to-moderate mental health concerns in pediatric and perinatal patients.

Webinar Wednesday Series 2026

Join Project TEACH for its Webinar Wednesday series, featuring both child and adolescent as well as perinatal mental health topics. These virtual sessions offer clinical insights and practical strategies that can be immediately integrated into primary care workflows. Webinar details are listed below.

Specialized Training Programs

Perinatal ROSE Training

Perinatal ROSE (Reach Out, Stay Strong, Essentials) training is an evidence-based, five-session preventive intervention based on interpersonal psychotherapy that has been clinically proven to significantly reduce the incidence of postpartum depression among at-risk pregnant individuals. Scheduled for Thursday, September 17, 2026, from 8:30 a.m. to 1 p.m. via Zoom, this training will be presented by Vanessa Tirone, PhD, and Ellen Poleshuck, PhD.

The program is specifically designed for NYS maternal care and mental health providers, including obstetricians, family physicians, midwives, nurses, doulas, community health workers, and social workers. Participants will learn to recognize the core content and structure of the five ROSE sessions, apply clinical engagement and teaching techniques to deliver the program effectively, and develop implementation plans tailored to their specific patient populations. To register and access additional resources, providers should refer to the Project TEACH "ROSE: Training for NYS Providers in a Program that Prevents Perinatal Depression" web page.

Child and Adolescent Mental Health Intensive Training (Two-Day Series)

The "Child and Adolescent Mental Health Intensive Training" is a virtual, comprehensive two-day series scheduled for Sunday, October 18, 2026, and Monday, October 19, 2026, from 8 a.m. to 5 p.m. via Zoom. This program is designed to enhance provider skills to assess, treat, and manage mental health concerns in child and adolescent patients, focusing on providing practical tools and strategies for primary care clinicians who treat pediatric patients and their families.

Spanning over two full days, this intensive training also offers participants the opportunity to earn 15.0 CME credits. To register and access additional resources, providers should refer to the Project TEACH "Intensive Training: Child and Adolescent Mental Health for Primary Care Clinicians" web page.

In-Person Perinatal Foundations Training

The In-Person Perinatal Foundations training, titled "Foundations in Perinatal Mental Health: Your Role in Support, Screening, and Treatment," will take place on Friday, November 13, 2026, from 9 a.m. to 4 p.m. at The Strathallan Hotel in Rochester, NY. Led by reproductive psychiatrists, psychologists, and social workers, this comprehensive course provides participants with foundational skills for screening and managing perinatal mood and anxiety disorders.

Registration for this event opens on Monday, August 31, 2026. Providers should refer to the Project TEACH "Foundations in Perinatal Mental Health: Your Role in Support, Screening and Treatment" web page, when registering. Interested providers are encouraged to sign up for registration alerts on the Project TEACH "Stay Connected With Project TEACH" web page, as seating is limited.

New Clinical Resources and Scholarship Opportunities

Perinatal Mental Health Toolkit

Project TEACH has launched a new, evidence-based clinical toolkit designed to support point-of-care decision-making for perinatal and pediatric clinicians titled, Perinatal Mental Health Toolkit. The toolkit features interactive links to screening tools, clinical algorithms, and referral resources.

Perinatal Mental Health Certification (PMH-C) Scholarships

To address financial barriers and expand the network of specialized maternal mental health providers in NYS, Project TEACH is offering 30 to 40 scholarships in 2026 to cover the costs associated with obtaining the Perinatal Mental Health Certification (PMH-C) credential through Postpartum Support International (PSI). The application deadline for this third cycle is October 1, 2026. Detailed eligibility criteria and application forms can be accessed directly on the Project TEACH Scholarship Portal.

About Project TEACH

Project TEACH is the NYS psychiatry access program for child, adolescent and perinatal mental health. In addition to training and webinar opportunities, Project TEACH offers referral support to healthcare clinicians and allied health professionals. Telephone consultations with child/adolescent or perinatal psychiatrists are available to primary care, OBGYN, pediatric and psychiatric clinicians in NYS.

Questions and Additional Information

• Questions regarding Project TEACH trainings and webinars should be directed to the Project TEACH Clinical Services Warmline at (855) 227-7272, between Monday through Friday, from 9 a.m. to 5 p.m.
• For information on Project TEACH services, past webinars and trainings, and clinical and family resources, providers should visit the Project TEACH website.

Stay Covered: Preparing for Federal Policy Changes

The federal Budget Reconciliation Act of 2025 (H.R.1) makes big changes that go beyond just updating policies — it creates real challenges for the health care system that millions of New Yorkers depend on. To help protect as many New Yorkers as possible from losing their health coverage, New York State is asking community partners to share information about these changes and what people need to do through the Stay Covered campaign.

To help with this effort, the following communication tools are available for partners and stakeholders on the Implementing H.R.1 Communications Tool Kit:

• educational materials in 27 languages, including fact sheets, flyers, and posters;
• videos and pre-written posts to share on social media accounts;
• co-branding guidelines for partners who would like to develop their own materials and co-brand them with New York's Stay Covered campaign; and
• Frequently Asked Questions for partners to provide information about what is changing and how they can help.

The tool kit will continue to be updated with the latest news and available resources. Providers are encouraged to share these resources to help inform New Yorkers about the changes that are coming.

Federal Community Engagement Requirements for New York State Medicaid Coverage

Starting January 1, 2027, some people who have New York State (NYS) Medicaid coverage will need to show they are working, going to school, helping out in the community, or participating in job training to keep their health coverage. This is a new federal rule from the federal government.

Starting mid-August and continuing through September 30, 2026, NYS Medicaid members who may be subject to this requirement will receive a notice by mail or email depending on their communication preferences from NY State of Health.

Providers are encouraged to follow New York's Stay Covered campaign to learn more about work and community engagement requirements for NYS Medicaid coverage, as well as other changes coming to the NYS Medicaid program.

Additional Information

Additional information is available on the NY State of Health "Changes to Medicaid Coverage" web page.

NYRx, the Medicaid Pharmacy Program: Prior Authorization Update

On February 26, 2026, the New York State (NYS) Medicaid Drug Utilization Review Board (DURB) recommended changes to NYRx, the Medicaid Pharmacy program. The Commissioner of Health reviewed the DURB recommendations and approved the following changes.

Effective July 16, 2026, the following Drug Utilization Review (DUR) program clinical criteria requirements will be implemented:

• Topical immunomodulators used in the treatment of atopic dermatitis:
  • Trial of a medium, high, or very high potency preferred topical corticosteroid.
  • Prior authorization (PA) is required when a topical Janus kinase inhibitor and systemic immunomodulator are used concurrently.
  • Quantity limits:
    • Ruxolitinib: 60 grams per month and 120 grams per year.
    • Delgocitinib: 30 grams per month and 60 grams per year.
• Systemic immunomodulators used in the treatment of atopic dermatitis:
  • Trial of a medium, high, or very high potency preferred topical corticosteroid or a preferred topical immunomodulator.
  • Systemic Janus kinase inhibitors:
    • Trial of a medium, high, or very high potency preferred topical corticosteroid and a preferred systemic immunomodulator.
• Doxepin cream:
  • Trial of a preferred topical corticosteroid or preferred topical immunomodulator.
  • Quantity limits of 45 grams per month and 180 grams per year.
• Topical steroids:
  • Low, medium, and high potency topical corticosteroids: A yearly limit of 12 claims, or 360 grams.
  • Very high potency topical corticosteroids: A yearly limit of six claims, or 240 grams.
  • Very high potency topical corticosteroids: An age edit to allow coverage for patients 12 years of age and older.
• Neurokinin Receptor Antagonists:
  • Trial of one hormone replacement therapy regimen, unless otherwise contraindicated.

For additional information about the DURB, providers should refer to the NYS Department of Health "Drug Utilization Review (DUR)" web page.

The NYRx, the Medicaid Pharmacy Program Preferred Drug List has been updated to reflect the clinical criteria requirements above along with additional information on drugs requiring PA. To review a list of preferred products that generally do not require a PA when prescribed according to Food and Drug Administration 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 request can also be submitted by telephone at (877) 309-9493 or by fax at (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 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:

• Prime Therapeutics™ NYRx, the Medicaid Pharmacy program website
• eMedNY website
• NYS Department of Health "Welcome to NYRx, the Medicaid Pharmacy Program" web page
• NYS Department of Health website
• Prime Therapeutics™ NYRx, the Medicaid Pharmacy Program "NYRx Education & Outreach" web page

Questions and Additional Information:

The NYRx Education and Outreach Call Center is available by telephone at (833) 967-7310 or by email at NYRxEO@primetherapeutics.com, from 8 a.m. to 5 p.m. (ET), Monday through Friday, excluding holidays.

NYRx Education and Outreach hosts virtual office hours each week for stakeholders to ask questions about NYRx and care coordination. Prescribers and pharmacists should visit the Prime Therapeutics™ NYRx, the Medicaid Pharmacy Program "NYRx Education & Outreach" web page, for more information.

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

As a reminder, unlicensed interns, residents, and foreign physicians in training programs are eligible to prescribe for New York State (NYS) Medicaid members without enrollment as a NYS Medicaid provider.

NYS Medicaid requires enrollment of all licensed prescribers who serve NYS Medicaid members, including prescribing practitioners, as identified on pharmacy prescriptions, per the Centers for Medicare and Medicaid Services and federal regulations.

There are two exceptions to the provider enrollment requirement:

1. Unlicensed interns, residents and foreign physicians in training programs

2. Out-of-state (OOS) licensed prescribers that are treating a NYS Medicaid member for a single instance of emergency care within 180 days.

OOS prescribers must be enrolled in Medicare with an "approved" status or are enrolled in their own state's Medicaid program for the below override.

Pharmacy Billing Guidance Exceptions for Non-Enrolled Prescribers in NYS Medicaid

Pharmacies billing for prescriptions written by unlicensed Interns, residents and foreign physicians in training programs will need to utilize point of service overrides for claim submission. Pharmacies will receive a reject code/POS rejection message for prescriptions written by a non-enrolled prescriber. Pharmacies should refer to the override guidance provided below for the above exceptions specific to NYRx, the Medicaid Pharmacy program.

• In Field 439-E4 (Reason for Service Code): Enter "PN" (Prescriber Consultation).
• In Field 441-E6 (Result of Service Code): Enter applicable value ("1A", "1B", "1C", "1D", "1E", "1F", "1G", "1H", "1J", "1K", "2A", "2B", "3A", "3B", "3C", "3D", "3E", "3F", "3G", "3H", "3J", "3K", "3M", "3N", "4A").
• In Field 420-DK (Submission Clarification Code): Enter "02" (Other Override).

Documentation Reminder

As previously stated in the Reminder: Unlicensed Interns, Residents and Foreign Physicians in Training Programs as Prescribers article published in the September 2023 issue of the Medicaid Update, with regard to any prescriptions issued to a NYS Medicaid member by any unlicensed prescriber, records should be contemporaneously created and maintained supporting the issuance of such prescription. This requirement applies to all residents, interns and foreign physicians who participate in any medical training program. The documentation must include the National Provider Identifier of the prescriber and NYS Medicaid provider who is responsible for supervising the prescribing unlicensed resident, intern or foreign physician in a training program.

All records related to the issuance of a prescription by non-enrolled prescribers are subject to production upon request by NYS, including but not limited to, the NYS Department of Health, Office of the Medicaid Inspector General, Office of the State Comptroller, and the NYS Office of the Attorney General.

Additional Information:

• Prescribers should refer to the Medicaid Provider Enrollment Compendium (MPEC).
• Billing questions should be directed to the eMedNY Call Center at (800) 343-9000.
• Questions regarding this communication should be directed to NYRx@health.ny.gov.