Nebraska Department of Health and Human Services
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Nebraska Medicaid Program

Provider Information

Nursing Facility 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: PDF Contacts Medicaid.

PDF Regulations

Chapter 1 Administration
Chapter 2 Provider Participation
Chapter 3 Payment for Medical Services
Chapter 12 Nursing Facility Services
Chapter 36 Hospice Services

PDF Appendices (Forms, Reports and Instructions)

471-000-2 Form DM-5, “Physician’s Confidential Report” and Completion Instructions
471-000-28 Instructions for Completing Form ASD-100, “De-Institutionalization Referral”
471-000-41 Instructions for Completing Form FA-66, “Long Term Care Cost Report”
471-000-43 Instructions for Completing Form MC-75, “MDS 2.0”
471-000-44 Instructions for Completing Form MC-75Q, “MDS 2.0 Quarterly Review”
471-000-45 Instructions for Completing Form MC-75-7, “MDS 2.0 Section S”
471-000-46 Instructions for Completing Form MC-75R, “MDS 2.0 Re-entry Tracking Form”
471-000-47 Instructions for Completing Form MC-75D, “MDS 2.0 Discharge Tracking Form”
471-000-48 Instructions for Completing Form MC-75PS, “MDS 2.0 Resident Assessment Protocol Summary Form”
471-000-49 Claims Submission Table
471-000-50 Standard Electronic Transaction Instructions
471-000-68 Form IM-8, “Notice of Finding”, and Completion Instructions
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
471-000-82 Instructions for Completing Turnaround MC-4, “Long Term Care Facility Turnaround Billing Document”
471-000-85 Explanation of Remittance Advice and Refund Requests Report
471-000-87 Example of Form MC-2, “Electronic Attachment Control Number Form”
471-000-99 Medicaid Claim Adjustment and Refund Procedures
471-000-100 Form MCP575, “Casualty Insurance Policy Information Sheet”
471-000-104 Instructions for Completing Form MC-81, “Medical Assistance Long Term Care Provider Agreement”
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)
471-000-203 Instructions for Completing Form MC-9NF, “Prior Authorization for Nursing Facility Care”
471-000-211 Form MC-10, “Prior Authorization Document Adjustment”, and Completion Instructions
471-000-220 Instructions for Completing Form DSS-14AD, “Functional Criteria”
471-000-221 Instructions for Completing Form DM-5, “Physician’s Confidential Report,” for the Preadmission Screening Process (PASP)
471-000-222 Instructions for Completing Form DM-5-LTC, “Long Term Care Evaluation” for the Preadmission Screening Process (PASP)
471-000-224 Instructions for Completing Form DPI-OBRA2, “Evaluation and Service Recommendation”
471-000-225 Instructions for Completing Form DPI-OBRA2 MR/RC, “Evaluation and Service Recommendation” – MR/RC
471-000-227 Instructions for Completing Form DPI-OBRA5, “Notice of PASARRP Findings”
471-000-228 Instructions for Completing Form DPI-OBRA6, “Assurances”
471-000-229 Instructions for Completing Form DPI-OBRA7, “Referral for Community-Based Services”
471-000-230 Instructions for Completing Form DPI-OBRA8, “Authorization for Release of Information”
471-000-231 Instructions for Completing Form DPI-OBRA-9, “PASARRP Summary of Findings Report”
471-000-233 Qualified Mental Retardation Professional (42 CFR 483.430)
471-000-234 Guidelines for Social History

PDF Provider Bulletins

Number Subject Date
08-15

Reimbursement for Wheelchairs Provided to Clients Residing in Nursing Facilities (Bulletin to Nursing Facilities)

 05/01/08
08-12

DHHS Website Email Notification Feature, Online Provider Handbooks and Provider Bulletins, Electronic Claims, Funds Transfer and Other Options

 05/12/08
08-06

Tamper-Resistant Presciption Pads for the Nebraska Medicaid Pharmacy Program (Revised)

 03/14/08
07-20

Tamper-Resistant Prescription Pads for the Nebraska Medicaid (Rescind effective 03/14/08)

 09/05/07
07-10

New Medicaid Claim Reports – New Process for Reporting Deleted Medicaid Claims

 05/09/07
07-07

Clarification of Facility Obligation to Reimburse for Nurse Aide Training and Competency Evaluation Program (NATCEP) Costs

 02/26/07
05-08

Reimbursement for Wheelchairs Provided to Clients Residing in Nursing Facilities (Bulletin to DME Suppliers) (Rescind effective 05/01/08)

 05/22/05
05-01

2005 revisions to Long Term Care Facility Turnaround/Add-on billing document (mc-4) Format and completion instructions

 01/14/05

Go to Rules and Regulations and Provider Bulletins for all Medicaid regulations, appendices and bulletins.

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