Issue #25-09

The purpose of this Alert is to remind SSHSP billing providers when it’s necessary to obtain a new written order/referral for SSHSP services.

A written order/referral is required for Medicaid reimbursement of medically necessary services included in an IEP. Medical necessity is established by the written order/referral. Written orders/referrals must include details about the service(s) being ordered. Details such as the frequency and duration of the service must be included on the written order/referral. When there is a change to a medically necessary service in an IEP a new written order/referral is necessary to support Medicaid billing.

1. When the actual frequency and duration of the ordered service is included on the written order/referral it:
   • Can be completed and signed before or after IEP is completed.
   • Supports Medicaid billing for services that are also included in the IEP.
   • Will no longer support Medicaid billing when there is a change to the service being furnished to a student pursuant to their IEP. This includes, but is not limited to, changes to the frequency or duration of the services, and/or if the service changes from individual to/from group, and when the annual review is completed, and the student’s next IEP is developed.
2. When the phrase “per the IEP” is included on the written order/referral as a reference to the frequency and duration of the service detailed in an existing IEP it:
   • Does not support Medicaid billing if completed and signed before the IEP.
   • Supports Medicaid billing for services that are included in the existing IEP.
   • Will no longer support Medicaid billing when there is a change to the service being furnished to a student pursuant to their IEP. This includes, but is not limited to, changes to the frequency or duration of the services, and/or if the service changes from individual to/from group, and when the annual review is completed, and the student’s next IEP is developed.
3. When the written order states the frequency and duration of the ordered service and includes the phrase “per the IEP” it:
   • Does not support Medicaid billing if completed and signed before the IEP.
   • Supports Medicaid billing when the frequency and duration on the order match the frequency and duration in the IEP that is in place when the order is signed.
   • Will no longer support Medicaid billing when there is a change to the service being furnished to a student pursuant to their IEP. This includes, but is not limited to, changes to the frequency or duration of the services, and/or if the service changes from individual to/from group, and when the annual review is completed, and the student’s next IEP is developed.

Note: SSHSP billing providers will no longer be able to bill Medicaid when written orders/referrals contain the phrase "per the IEP" beginning 7/1/2026 (effective service date).

If you have any questions or comments regarding this alert, please contact the NYS Department of Health at (518) 473-2160 or at SSHSP@health.ny.gov, or the NYS Education Department, Medicaid Unit at medined@nysed.gov.