Nebraska
Medicaid Program
Provider Information
Hospital 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)
| 471-000-10 |
Instructions for Completing “Nebraska Medicaid Telehealth Patient
Consent” Form |
| 471-000-49 |
Claims Submission Table |
| 471-000-50 |
Standard Electronic Transaction Instructions |
| 471-000-51 |
Form CMS-1450 (UB-92), “Health Insurance Claim Form”, (Formerly
HCFA-1450) |
| 471-000-70 |
Nebraska Medicaid Billing Instructions for Medicare Crossover Claims |
| 471-000-73 |
Form MS-6, “Ambulatory Room and Board Agreement”, and Completion
Instructions |
| 471-000-78 |
Nebraska Medicaid Form Locator Requirements for Form CMS-1450 (UB-92) |
| 471-000-79 |
Form EA-160, "Record of Health Cost - Share of Cost - Medicaid
Program", and Completion Instructions |
| 471-000-83 |
Billing Instructions for Hospital Services |
| 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 |
| 471-000-91 |
Form MC-20, “Medicaid Hospital Provider Agreement”, and
Completion Instructions |
| 471-000-96 |
Form MC-83, “Mental Health/Substance Abuse Treatment Planning
Document for Outpatient Services”, and Completion Instructions |
| 471-000-99 |
Medicaid Claim Adjustment and Refund Procedures |
| 471-000-100 |
Form MCP575, "Casualty Insurance Policy Information Sheet" |
| 471-000-109 |
Form MMS-100, “Serilization Consent Form”, and Completion
Instructions
|
| 471-000-110 |
Form MMS-101, “Informed Consent for Hysterectomies”, and
Completion Instructions |
| 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 |
| 471-000-129 |
Explanation of Deleted Medicaid Claims and Medicaid Claims In Process over
30 Days Report (MCP564-DS) |
| 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 |
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. |
