Nebraska
Medicaid Program
Provider Information
Durable Medical Equipment, Medical Supplies, Orthotics and
Prosthetics Provider Handbook
The links below comprise your Nebraska Medicaid Provider Handbook. This
handbook is your primary resource for information about the Nebraska Medicaid Program,
including program regulations, service coverage requirements and limitations, forms,
billing requirements, and payment information.
Please review this handbook prior to providing services and requesting payment from
Nebraska Medicaid and share it with personnel who perform referrals, authorization, coding
and claims submission for your office.
If you have questions or comments about this information, contact the Medicaid Program
Specialist for the type of service:  Contacts.
Regulations
Appendices (Forms, Reports and Instructions)
| 471-000-49 |
Claims Submission Table |
| 471-000-50 |
Standard Electronic Transaction Instructions |
| 471-000-55 |
Billing Instructions for Durable Medical Equipment, Medical Supplies,
Orthotics and Prosthetics |
| 471-000-58 |
Example of Form CMS-1500, "Health Insurance Claim Form"
(formerly HCFA-1500) |
| 471-000-70 |
Nebraska Medicaid Billing Instructions for Medicare Crossover Claims |
| 471-000-79 |
Form EA-160, "Record of Health Cost - Share of Cost - Medicaid
Program", and Completion Instructions |
| 471-000-85 |
Explanation of Remittance Advice and Refund Requests Report |
| 471-000-87 |
Example of Form MC-2, "Electronic Attachment Control Number
Form" |
| 471-000-90 |
Form MC-19, "Medical Assistance Provider Agreement" and
Completion Instructions |
| 471-000-99 |
Medicaid Claim Adjustment and Refund Procedures |
| 471-000-100 |
Form MCP575, "Casualty Insurance Policy Information Sheet" |
| 471-000-121 |
Explanation of Form PDS-38B, "Nebraska Health Connection ID
Document" |
| 471-000-122 |
Nebraska Health Connection: Listing of Plans and Vendors |
| 471-000-123 |
Explanation of Nebraska Medicaid Eligibility Documents |
| 471-000-124 |
Instructions for Using the Nebraska Medicaid Eligibility System (NMES) |
| 471-000-127 |
Explanation of Deleted Medicaid Claims Weekly Report (MCP564-D) |
| 471-000-128 |
Explanation of Medicaid Claims in Process Over 30 Days Report (MCP564-S) |
| 471-000-206 |
Form MS-77, "Request for Prior Authorization," and Completion
Instructions |
| 471-000-207 |
Instructions for Completing Form MS-78, "Augmentative Communication
Device Selection Report" |
| 471-000-208 |
Form MS-79, "Wheelchairs and Wheelchair Seating System Equipment
Selection Report," and Completion Instructions |
| 471-000-209 |
Form MS-80, "Air Fluidized and Low Air Loss Bed Certification of
Medical Necessity," and Completion Instructions |
| 471-000-507 |
Nebraska Medicaid Practitioner Fee Schedule for Durable Medical Equipment,
Medical Supplies, Orthotics and Prosthetics |
Provider Bulletins
Go to Rules
and Regulations and Provider Bulletins
for all Medicaid regulations, appendices and bulletins.
Documents in PDF format require the use of Adobe Acrobat Reader
which can be downloaded for free from Adobe Systems,
Inc. |
