Nebraska
Medicaid Program
Provider Information
Hearing Aid 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
Medicaid.
Regulations
Appendices (Forms, Reports and Instructions)
| 471-000-3 |
Form DM-5H, “Physician’s Report on Hearing Loss” and
Completion Instructions |
| 471-000-49 |
Claims Submission Table |
| 471-000-50 |
Standard Electronic Transaction Instructions |
| 471-000-56 |
Billing Instructions for Hearing Aid Services |
| 471-000-58 |
Example of Form CMS-1500, "Health Insurance Claim Form"
(formerly HCFA-1500) |
| 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) |
| 471-000-126 |
Procedure Codes Subject to Copayment Requirements |
| 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) |
| 471-000-205 |
Form MC-9S, “Prior Authorization Document for Hearing Aids”, and
Completion Instructions |
| 471-000-508 |
Nebraska Medicaid Practitioner Fee Schedule for Hearing Aid Services |
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 dowloaded for free from Adobe Systems,
Inc. |
