Claim Form A

eMedNY 150001

eMedNY 150002

Pharmacy Claim Form

CMS UB-04

Dental, Transportation

Fee for Service

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 - eMedNY 389702 (new)
• Transportation Prior Approval - eMedNY 389701 (old)
• Group Transportation Prior Approval - eMedNY 410601 (old)
• 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)