Penguin Health
New York · Medicaid · Applied behavior analysis
OMIG published its ABA audit protocol. The lookback reaches 2021.
On June 29, 2026 the New York Office of the Medicaid Inspector General posted a dedicated audit protocol for ABA: 18 numbered criteria under which a claim is disallowed, covering service dates from August 1, 2021 through June 25, 2026. Anyone who billed New York Medicaid for ABA in the last five years now knows exactly how those claims will be read. The documentation criteria map to the eMedNY policy manual, and the matching rule set lives in the rules library in the Penguin Health app.
A dedicated OMIG protocol for applied behavior analysis.
Numbered, from missing documentation to school settings and stale treatment plans.
August 1, 2021 through June 25, 2026. Past claims are in scope.
Criterion 3: patient identity, rendering provider, the services, the location.
The protocol
What OMIG disallows, and where the note decides it
Most of the 18 criteria are chart-level: a referral missing one of its seven required items, a treatment plan older than six months, a missing annual status report, supervision documentation absent from the member's record. Those are won or lost in the file. But the criteria that run on every single claim are note-level, and they are the ones a busy practice fails by accident: the four documentation elements of criterion 3, and units billed in excess of units documented under criterion 4.
- A claim is disallowed when the documentation of service is missing or inaccurate as to identifying patient information, the rendering provider, the services provided, or the location of service.
- Units billed in excess of the units documented are disallowed.
- ABA in school settings is non-reimbursable. Place of service 03 on an ABA claim is a disallowance on its face.
- Clinical documentation includes the specific goals and associated data to determine progress, the weekly hours by provider type, and the locations of service.
- An LBA supervises at least 5% of each unlicensed technician's hours per month with two face-to-face contacts, and the supervision is documented in the patient file. Claims are disallowed when it is missing.
- A valid referral with its seven items, a treatment plan updated at least every six months, and the annual status report to the referring practitioner.
The checklist
What a New York ABA note has to show
Each item below names the OMIG criterion or manual section behind it and the Penguin rule that checks it. New York sets no note-completion deadline, so none is claimed.
| The note shows | What that means in practice | Source | Rule |
|---|---|---|---|
| Identifying patient information | The patient identified on the documentation itself, name plus a second identifier. | OMIG crit. 3 | NY-1 |
| The rendering provider | Who rendered the service, by name and credential or title. | OMIG crit. 3 | NY-2 |
| The services provided | What was delivered in the session, not only that a session occurred. | OMIG crit. 3 | NY-3 |
| The location of service, matching the billing | Where the service happened, consistent with the billed place of service. | OMIG crit. 3 · §8.3 | NY-4 |
| Units supported by the documentation | The billed units against what the documented session supports. Excess units are the disallowance. | OMIG crit. 4 | NY-5 |
| Goals and associated data | The specific goals addressed with data to determine progress. | §8.3 | NY-6 |
| No school settings | Place of service 03 on an ABA claim fails outright. | OMIG crit. 10 | NY-7 |
| In-session direction on 97155 | The analyst directing treatment or modifying the protocol. Supervision away from any session does not support the code. | manual supervision policy | NY-8 |
ABA moved into New York Medicaid managed care on January 1, 2023, so plan rules layer on top of the FFS manual for enrolled members.
Records are kept at least six years, and for minors until the patient turns 22.
Two 12.5% Medicaid rate cuts landed in October 2025 and April 2026. The lookback still reaches every claim billed since August 2021.
In the rules library
Eight New York rules, ready to turn on
Open the rules library in the Penguin Health app, choose New York Medicaid ABA, and click Add to organization. Rules your organization already has are left alone, so adding the set twice only fills gaps. After adding, edit any rule or add your own alongside them.
Each rule runs only on notes billed to New York Medicaid payers. Penguin checks the CentralReach payer name, so a New York rule never fires on a commercial note in the same organization, and an organization whose payer names differ edits that match after adding the set.
Penguin reads signed session notes from CentralReach, read-only, after signature and before the claim, and runs the set on every note. Deterministic rules compare record fields. AI rules are read by the AI, which returns a pass or fail with a one-sentence reason.
Eight rules built against the OMIG audit protocol and the eMedNY policy manual: the criterion-3 documentation elements, units support, goals with data, the school-setting exclusion, and 97155 direction.
- reviewed
- Oct 19, 2026
- runs on
- Notes billed to New York Medicaid payers
- sources
- OMIG ABA audit protocol, Jun 29, 2026 · eMedNY ABA manual v2025-1
- watching
- The eMedNY manual index and the OMIG protocol
Every failure ships with QA guidance for that program code: an educational email, numbered action steps, and a QA email pre-filled with the date of service and a link to the note. Each reviewer action is written to a write-once audit log with seven-year retention, which is longer than OMIG's lookback. Billing Medicaid in more than one state? The rules library covers sixteen, including Pennsylvania and Massachusetts.
Maintained by Penguin
We watch OMIG and eMedNY so the rules never go stale
New York reissued its ABA manual in October 2025 and posted the audit protocol eight months later. The New York set is tied to those documents, not to a template written once.
The eMedNY ABA manual index, where new manual versions appear first, and the OMIG protocol itself. Penguin fetches the sources on a schedule and archives every revision.
We rewrite the affected rule, cite the document that changed it, and date the review. The set shows its sources and review date in the library.
An updated rule runs in the next scheduled validation and on demand against notes you have already reviewed, which matters in a state with a five-year lookback.
- ABA moves into managed care
Plan rules layer on top of the FFS manual for enrolled members.
- eMedNY reissues the ABA manual
Version 2025-1, the current policy text behind the documentation criteria.
- OMIG posts the ABA audit protocol
18 disallowance criteria, service dates August 1, 2021 through June 25, 2026.
LibraryNY-1 through NY-8 are built against it.
- New York set reviewed
Checked against the protocol and manual version 2025-1. Current.
- WatchingThe next manual version and protocol revision
When either changes, the set is updated and every organization using it gets the change.
Next step
Run a month of New York notes through Penguin
Bring one month of 97153 and 97155 notes. We add the New York set from the rules library, run it, show every finding beside the OMIG criterion it maps to, and hand your QA lead the fix for each one. Or get a demo account and click through Penguin on your own time first.