Trusted by 125+ New York behavioral health agencies
New York billing is complex—and constantly changing. Qualifacts combines state-ready EHR configurations with expert billing services to help agencies reduce risk, improve reimbursement accuracy, and stay ahead of Medicaid, Managed Care, OMH, and OASAS rules.
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Regulation Changes That Will Affect Your EHR in 2026
New York’s billing regulations heading into 2026 bring major changes that directly impact how agencies document, code, and bill for services. With new enforcement and rate logic, your EHR must keep pace to prevent denials and protect revenue.
What changed
In late 2025, New York Medicaid Managed Care plans began strictly enforcing institutional billing for behavioral health services. OMH and OASAS claims must now use 837I/UB-04 formats with mandatory rate codes aligned to program licensing, service definitions, and APG logic.
Why it matters
For large agencies, even minor misconfigurations can trigger systemic denials and delayed payments across programs. Errors often go unnoticed until AR grows or denial rates spike.
Why the EHR matters
Your EHR must enforce correct claim structures, apply rate codes consistently, and block noncompliant claims. Without this, agencies resort to manual workarounds that fail under scale.
What changed
New York continues to update Ambulatory Patient Group (APG) methodology, including base rates, peer group logic, and how procedures and modifiers group for payment. These changes often roll out quietly but directly affect reimbursement calculations across outpatient behavioral health services.
Why it matters
APG changes rarely cause immediate denials. Instead, agencies experience payment variance, underpayment, or unexplained revenue erosion over time. Without clear visibility, organizations may not realize reimbursement has shifted until months later.
Why the EHR matters
An EHR in New York must:
- Support APG-aware billing logic
- Maintain accurate relationships between procedures, modifiers, and rate codes
- Provide reporting that connects services delivered to reimbursement outcomes
Without these capabilities, agencies struggle to pinpoint payment changes and revenue leaks.
What changed
OMH finalized and enforced PROS redesign billing rules effective April 1, 2025. Managed Care plans updated adjudication logic to reflect new service definitions, billing structures, and reimbursement expectations. Many agencies felt the impact later in 2025 as claims were reprocessed or retroactively denied.
Why it matters
PROS programs are common in New York, especially at enterprise agencies. When billing rules change at the program level, organizations often face:
- Retroactive denials or recoupments
- Payment delays
- Increased billing staff workload to interpret new rules
- These impacts frequently surface months after go-live.
Why the EHR matters
PROS billing complexity requires the EHR to:
- Align documentation with updated service definitions
- Apply program-specific billing logic automatically
- Reduce reliance on manual interpretation by staff
- When program rules change, manual workflows break quickly.
What changed
New York enacted a commercial reimbursement mandate requiring certain commercial payers to reimburse OMH and OASAS outpatient services at no less than Medicaid rates. While effective January 2025, enforcement continues through contract renewals into 2026, meaning agencies experience the impact unevenly.
Why it matters
Many agencies assume parity is being honored, but without strong reporting, underpayments often go unnoticed. Identifying noncompliance requires accurate billing data and the ability to compare expected versus actual reimbursement.
Why the EHR matters
Before agencies can challenge underpayment, their EHR must:
- Produce clean, defensible billing data
- Support payer-specific reporting
- Maintain consistent rate code and service mapping
Parity enforcement starts with data integrity.
Take the Complexity Out of New York Requirements
Collect, manage, and leverage the data you need. Support all aspects of New York billing and compliance, with continuous system updates based on ever-evolving state regulatory changes.
New York billing rules are complex and constantly changing. Agencies need more than technology—they need expert support to stay compliant with Medicaid, Managed Care, OMH, and OASAS requirements.
Qualifacts delivers New York–ready EHR configurations, continuous regulatory updates, and dedicated billing specialists to reduce risk, improve reimbursement accuracy, and scale operations. Trusted by 125+ behavioral health agencies statewide, we help organizations move from reactive billing to proactive financial control.
In today’s rapidly evolving healthcare landscape, seamless care coordination and interoperability are more crucial than ever. Qualifacts allows you to connect seamlessly to other systems and organizations to enhance client-centered care, ensure compliance, and streamline operations.
- Promote coordinated, client-centered care with configurable fields and efficient integrations
- Drive interoperability and compliance with a proven HL7 solution and FHIR APIs
- Facilitate care coordination through versatile integrations with RHIOs (Healthix, HEALTHeLINK, Bronx, Rochester, etc.)
- Send lab orders, receive and view results without physical scans, faxes, or manual entry
- Integrate the ASAM criteria directly into your EHR to provide a holistic, biopsychosocial assessment
Advanced analytics and granular configurability allow you to track key metrics for the support value-based payment models and population health outcomes.
- Easily measure Clinical Quality Measures (CQMs) with our Outcome Reporting Platform
- Clinical decision support built into programs and services, ensuring clinical documentation best practices are integrated into workflows
- Utilize BI dashboards to track progress, identify areas for improvement, and assess the effectiveness of interventions
- Configuration outcome dashboards for real-time data tracking on quality measures and program metrics
Collect, manage, and leverage the data you need with intuitive analytics tools. Qualifacts supports New York billing and compliance with continuous system updates based on ever-evolving state regulatory changes at no additional cost.
- Stay compliant with continuously updated and maintained New York State Reporting requirements, including OPWDD and OMH regulatory requirements
- Provides batch submission of substance use-related client data, and demographics to the Office of Addiction Services and Supports (OASAS)
- Simplify requirements with intuitive form development tools that ensure your agency can rapidly adjust
- Over 30 New York specific state form templates available
CCBHCs need technology that can easily adapt to unique requirements. Our industry-leading EHR solutions offer CCBHC outcome measures, superior clinical functionality, robust analytics reporting, interoperability, configurability and more.
- Functionality for CCBHC and Value-Based Reimbursement (VBR) care models
- PPS-1 (Prospective Payment System – Type 1) Billing of Claims
- “First Available” scheduling
- Qualifacts subject matter experts provide hands-on guidance and consulting
- Peer-led CCBHC user groups offer national collaboration to exchange best practices
- Our CCBHC strategic partnership includes state-specific knowledge, as well as training and support every step of the way
Bolster continuity and quality of care through the sharing of medical information with an integrated Primary Care module.
- Functionality supports both the delivery of primary and behavioral health care services to align with ongoing OMH initiative
- Access one integrated record and set of reports for clients
- Expanded medical profile (including SNOMED)
- Standardized collection method for history of present illness (HPI) and additional diagnoses
- Adherence to confidentiality requirements and data protocols across treatment areas
Work online and disconnected with a fully integrated, mobile solution for New York Home and Community Based Services.
- Integrated Electronic Visit Verification (EVV) capabilities support eMedNY’s NYSDOH Medicaid Management Information System integration
- 24/7 access to clinical tools for documenting, scheduling, tracking, and treating clients
- HIPAA compliant data easily captured on iPad, iPhone, Android enabled devices, netbooks, laptops, and/or tablet PCs
- Reduced administrative overhead and burden associated with paper timesheet processing
- Easily capture signatures for assessments and progress notes from clients
