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(Provider Manual §3.3.6), Full Copay, Part B Medicare/Medicaid Claims for outpatient hospital services billed on UB04 claim forms are also paid at theSee the UB-04 manual for proper completion of this field. Provider type specific manuals may provide additional guidance as it relates to NY Medicaid. Hospitals should prepare and electronically submit a UB-04 claim form. Timely Filing. All claims must be submitted to Fidelis Care within the timeframes 4. Healthcare Services (HCS) Department. 4. Health Management . The EPSDT/CTHP Provider Manual can be found on eMedNY. 10.07.2015 • Views New York StateUB04 Billing GuidelinesHOME HEALTH SERVICES[Type text] [Type text] 52.3.1 UB-04 Claim Form Field Instructions . care provider manual, use this manual unless your 4 | UnitedHealthcare Community Plan New York v.64_8.2022 NY Medicaid [Department of Social. INPATIENT HOSPITAL. New York State. UB-04 Billing Guidelines. 10/1/2015. Version 2015 - 01 eMedNY is the name of the New York State Medicaid system.