MedicaidPrior AuthHigh impact
NYS Medicaid Breast Cancer Selective Program Reimbursement Policy
Healthfirst·NY · General Surgery, Oncology, OB-GYN·Provider Update
Effective date
Apr 1, 2026
We identified it
Jun 20, 2026
Summary
Healthfirst now requires prior authorization for all breast cancer surgical procedures under the NYS Medicaid Breast Cancer Selective Program, and services must be performed only at state-approved facilities. Claims will be denied if performed at restricted facilities or without proper authorization.
Action Required
Before April 1, 2026: Billing team must update system to require prior authorization for all breast cancer surgical procedures (CPT codes 19120-19307) when performed with qualifying breast cancer diagnosis codes (C50, D05, Z85.3 series). Verify all procedures are scheduled only at NYS-approved facilities using the state facility lists. Update encounter forms to remind providers of authorization requirements. Claims performed at restricted facilities will be denied regardless of medical necessity.