| 471-000-7 |
Example of Form DM-8, “IPR-Institutions for Mental Disease Ages 21
and Under” |
| 471-000-8 |
Example of Form DM-9, “IPR-Institutions for Mental Disease Ages 65
and Older” |
| 471-000-10 |
Instructions for Completing “Nebraska Medicaid Telehealth Patient
Consent” Form |
| 471-000-40 |
Form FA-20, “Cost Report of Psychiatric and Chemical Dependency
Facilities for Medicaid Reimbursement”, and Completion Instructions |
| 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) |
| 471-000-58 |
Example of Form CMS-1500, “Health Insurance Claim Form”
(formerly HCFA-1500) |
| 471-000-64 |
Billing Instructions for Mental Health and Substance Abuse Services |
| 471-000-70 |
Nebraska Medicaid Billing Instructions for Medicare Crossover Claims |
| 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 |
| 471-000-85 |
Explanation of Remittance Advice and Refund Requests Report |
| 471-000-87 |
Example of Form MC-2, “Electronic Attachment Control Number
Form” |
| 471-000-89 |
Form MC-14, “Confidential Report”, and Completion Instructions |
| 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” |
| 471-000-102 |
Form MC-9, “Prior Authorization Document,” and Completion
Instructions for IMD’s |
| 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) |
| 471-000-129 |
Explanation of Deleted Medicaid Claims and Medicaid Claims In Process over
30 Days Report (MCP564-DS) |
| 471-000-211 |
Form MC-10, “Prior Authorization Document Adjustment”, and
Completion Instructions |
| 471-000-532 |
Nebraska Medicaid Practitioner Fee Schedule for Mental Health and
Substance Abuse Services |
| 471-000-540 |
Nebraska Medicaid Practitioner Fee Schedule for Injectables |
