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    v1.0.31
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyNew York Medicaid PDN Billing Policy Update | Open…
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    CurrentNew York State Department of HealthPolicy N/A

    Edit 02304 - Zero-Fill for Private Duty Nursing (PDN) Claims

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    This policy governs documentation, approval duration, and primary-insurance billing requirements for Medicaid private duty nursing claims subject to Edit 02304 zero-fill bypasses.

    Policy Summary
    PayerNew York State Department of Health
    PolicyEdit 02304 - Zero-Fill for Private Duty Nursing (PDN) Claims
    Policy CodePolicy N/A
    Change TypeAdministrative clarification and validity-period update
    Effective Date1/1/2026
    Next Review DateN/A
    Key ActionBill the primary insurance before requesting Medicaid reimbursement when PDN services are covered by that insurance.
    SourceLink
    POLICY UPDATE CHANGES

    New approvals for PDN zero-fill bypasses are valid for three years.

    Existing PDN zero-fill bypass approvals receive an extended validity period.

    Providers must document and bill covered primary-insurance benefits before requesting Medicaid reimbursement.

    3 yearsNew bypass validity
    2 triggersDocumentation triggers
    Primary payer firstBilling sequence

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Audit and recoupmentPotential consequence

    Primary-Insurance Billing Prerequisite

    Primary-Insurance Billing Prerequisite

    When PDN services are covered by the member’s primary insurance, the provider must meet both of the following requirements before requesting reimbursement from Medicaid.

    ALL of the following

    • Maintain documentation of the primary insurance benefit.
    • Bill the primary insurance before requesting reimbursement from Medicaid.

      Failure to comply may result in audit and recoupment of any Medicaid reimbursement paid in error.

    Zero-Fill Bypass Validity

    New zero-fill bypass validity
    Validity periodThree years for all new PDN zero-fill bypass approvals effective January 1, 2026.
    2026 new-case exampleDocumentation submitted for new cases in 2026 establishes a bypass valid through December 31, 2028.
    Next documentation dateNew primary-insurance documentation is not required until January 1, 2029, unless the member's primary insurance changes or a new primary plan is added.
    Existing approval extension
    Extended through dateExisting PDN zero-fill bypass approvals expiring on December 31, 2025, are extended through December 31, 2027.
    Next documentation dateNew primary-insurance documentation is not required until January 1, 2028, unless the member's primary insurance changes or a new primary plan is added.
    Applies toExisting approvals that expire at the end of the prior approval cycle.

    Required Provider Actions

    Documentation Required

    Submit primary-insurance documentation

    Submit documentation from the member’s primary insurance when requesting a new zero-fill bypass approval for private duty nursing (PDN) services.

    Billing Rule

    Bill primary insurance first

    If PDN services are covered by the primary insurance, maintain documentation of the primary-insurance benefit and bill the primary insurance before requesting reimbursement from Medicaid.

    • Document the primary-insurance benefit.
    • Bill the primary insurer first.
    • Request Medicaid reimbursement only after billing the primary insurance.
    Policy Summary
    PayerNew York State Department of Health
    PolicyEdit 02304 - Zero-Fill for Private Duty Nursing (PDN) Claims
    Policy CodePolicy N/A
    Change TypeAdministrative clarification and validity-period update
    Effective Date1/1/2026
    Next Review DateN/A
    Key ActionBill the primary insurance before requesting Medicaid reimbursement when PDN services are covered by that insurance.
    SourceLink
    On This Page
    Primary-Insurance Billing PrerequisiteZero-Fill Bypass ValidityRequired Provider Actions
    Documentation Required

    Update documentation after insurance changes

    New primary-insurance documentation is required when the member’s primary insurance changes to a different plan or when a new primary insurance plan is added to the member’s file.

    • Primary insurance changes to a different plan.
    • A new primary insurance plan is added to the member’s file.
    Denial Risk

    Avoid audit and recoupment

    Failure to maintain primary-insurance documentation and bill the primary insurance before requesting Medicaid reimbursement may result in an audit and recoupment of any Medicaid reimbursement paid in error.

    • Maintain documentation of the primary-insurance benefit.
    • Bill the primary insurance before requesting Medicaid reimbursement.