Billing Providers encountering situations which delay the ability to submit claims on a timely basis may enter an Extraordinary Circumstance (EC) in the EI-Hub's Billing Module. The EC represents the reason that claims could not be submitted within the Bureau’s timely filing guidelines. ECs are entered once for the entire date range the billing provider was affected and must be entered before submitted any claims for the affected time period. For more information, including a job aid on how to enter ECs, follow the link above.

Medicaid revised its denial reason for files processed and paid in November and replaced denial code CO200 with CO31. Providers will begin seeing CO31 denials in their Workable Claims queue within the Billing module. No action is required from providers at this time. To support this change, PCG is implementing a system update that will automatically move CO31-denied claims to Escrow, using the same methodology previously applied to CO200 denials. Follow the link for more information.

Claims that are sent to Medicaid must have an OPRA (Ordering/Prescribing/Referring/Attending) enrolled referring provider. Medicaid will deny claims billed with a referring who is not OPRA enrolled (including Speech Language Pathologists). It is the responsibility of the agency to confirm the credentials and proper Medicaid enrollment for all referring providers utilized on claims prior to billing.

New resources are now available in the Learning Management System, covering service authorizations and claiming for transportation and respite services. This article includes direct links to these resources—follow the link for more information.

An In The Loop article titled “Entering Commercial Insurance in the EI-Hub” released on 03/20/2025 provides guidance on entering commercial insurance. The article notes that commercial insurance companies often have multiple billing addresses for claims. However, with Covered Lives legislation, only the insurance company's name is required in the EI-Hub. Follow the link for more information.

The 2026 holiday schedule for the PCG Customer Service Call Center is now available. It outlines which days the Call Center will be open or closed, including adjusted observances for Columbus Day and Veterans Day. Follow the link for more information.

Use of the 'State Administrative Delay’ as the Extraordinary Circumstance (EC) to submit claims as a result of editing closed Individualized Family Service Plans (IFSPs) is now extended to December 31, 2026. Use of this EC reason should be limited to billing claims that were related to the reopening of closed IFSPs. Follow the link to view the In the Loop article, released on October 1, 2026, for additional directions on how to enter this reason in the Billing Module of the EI-Hub.

For New York City providers only: The initial payment of the 5% retroactive escrow that covers dates of service from October 2024 through June 2025 was scheduled to be paid on June 10, 2026. An unexpected delay has impacted this retroactive escrow payments. Resolution is currently underway, with payments anticipated by the end of the week. This delay is limited to the 5% retro escrow payments only and does not impact standard escrow payments, which will continue to be processed and paid as scheduled. A follow-up communication will be shared as soon as additional details are available.

All 835 files for Medicaid Cycle 2543, including the Medicaid retroactive 5% rate increase, are posted and available for review. An In the Loop article was sent yesterday with steps to view the increase in the Billing module. Follow the link above to access the article on the Learning Management System (LMS).

Effective June 1, 2026, New York Medicaid will implement a new editing rule that limits the number of times a claim may be submitted. Under this change, a claim will automatically deny after the fourth (4th) resubmission attempt, allowing a maximum of five (5) total submissions, including the original claim. Follow the link for more information.