MedicaidCoverageMedium impact
Update to the New York State Patient Centered Medical Home Billing Guidance
NY Medicaid·NY · Family Medicine, Internal Medicine, General Practice +1 more·Claims & Billing
Effective date
Jan 1, 2026
We identified it
May 10, 2026
Summary
New York State Medicaid updated Patient Centered Medical Home billing guidance effective January 1, 2026, including updated payment tables, quality reporting requirements, and provider revocation risk information. The policy also updated coverage criteria for wireless capsule endoscopy with specific billing codes and medical necessity requirements.
Action Required
For NY providers: Review updated PCMH billing guidance at NYS DOH website and ensure compliance with new quality reporting requirements. For gastroenterology practices: Update billing procedures for wireless capsule endoscopy to use CPT 91110 and 91111, ensure proper documentation of medical necessity per new criteria, and retain documentation for minimum 6 years. Contact PCMH@health.ny.gov for program questions.