Claim Form A

eMedNY 150001

Pharmacy Claim Form

CMS UB-04

Dental, Transportation

Fee for Service

Pharmacy

Rate Based

• Prior Approval Roster Request Form
• Order/Prior Approval Request - Pharmacy/DME, Nursing, Eye Care, Physician
• Order/Prior Approval Request - Dental Services
• Hearing Aid - Order/Prior Approval request
• High/Special Level of Care - Determination of Medical Eligibility
• Transportation Prior Approval
• Group Transportation Prior Approval
• Prior Approval Change Request Form
• Prior Approval Change Request Form Instructions
• Provider Fax Coversheet Form
• Provider Fax Coversheet Instructions

• Electronic Attachment Scanning Form
• Electronic Attachment Scanning Form Instructions

• Threshold Override Application Form Instructions
• Threshold Override Application (TOA)

These guides provide field by field instructions for completing eMedNY paper forms. Note: To ensure correct billing procedures for individual provider types, please refer to the associated Provider Billing Manual.

• Dental Claim Form Instructions
• DME & Hearing Aid Claim Form Instructions
• Nursing Registry Services Claim Form Instructions
• Nursing Services Claim Form Instructions
• Ordered Ambulatory and Laboratory Services Claim Form Instructions
• Pharmacy Claim Form Instructions
• Practitioner Claim Form Instructions
• Transportation Provider Claim Form Instructions