Nebraska
Medicaid Program
Provider Infomation
Personal Assistance Services 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)
| 471-000-60 |
Instructions for Completion of Form HHS-5N, “N-FOCUS Health and Human
Services Billing Document” |
| 471-000-92 |
Instructions for Completing Form MC-37E/S, "Service Provider Time
Sheet" |
| 471-000-94 |
Instructions for Completing Form MC-84, “Personal Assistance Provider
Check List” |
| 471-000-95 |
“Service Needs Assessment/Plan” |
| 471-000-105 |
Instructions for Completing Form MILTC-9, "Service Provider
Agreement" |
| 471-000-106 |
“Provider Authorization” |
| 471-000-107 |
Instructions for Completing Form MILTC-4D. "Physician/RN Statement
for Health Maintenance Activities" |
| 471-000-108 |
“Provider Authorization Update” |
| 471-000-112 |
Instructions for Completing Form IRS-2678, "Employer Appointment of
Agent" |
| 471-000-123 |
Explanation of Nebraska Medicaid Eligibility Documents |
| 471-000-515 |
Nebraska Medicaid Personal Assistance Services Rate Listing |
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. |
