Insurance Updates – June 2025

The New York State (NYS) Medicaid program has issued a reminder to all Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) providers regarding Opioid Treatment Program (OTP) services for members enrolled in the Recipient Restriction Program (RRP). OTP services, provided by programs certified as Article 32 outpatient programs by the Office of Addiction Services and Supports (OASAS), were formerly known as Methadone Maintenance Treatment programs. 

The RRP aims to enhance care coordination for NYS Medicaid members by reducing over-utilization of healthcare services and preventing fraudulent or abusive behaviors, such as forged prescriptions or doctor shopping. Under the RRP, members may be restricted to specific primary care providers, inpatient hospitals, or pharmacies if they exhibit patterns of excessive or conflicting healthcare use. However, OTP services, including methadone maintenance, are fully exempt from RRP coverage and payment restrictions. This means that medically necessary opioid use disorder services provided in OTPs must be covered by all NYS Medicaid MMC Plans for RRP-identified members without additional restrictions, authorizations, or referral requirements. Claims for OTP services cannot be denied due to RRP restrictions. 

For FFS claims, Article 32 OTP providers, identified by specialty code “922,” must use specific rate codes (e.g., 1036, 1039, 1564, 1567, 7969–7976, 1671, or 2973) when submitting claims. A system update to eMedNY, expected by July 24, 2025, will enhance the bypassing of OTP FFS claims for restricted recipients. OASAS is collaborating with the NYS Department of Health to ensure proper payment for services. For MMC-enrolled members, providers should follow the billing instructions of the individual MMC Plan, ensuring claims for OTP services are not denied due to RRP restrictions.