Ambulance Provider Handbook

 
2
Medicaid Related Assistance
Medicaid & Long-Term Care
 
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What you need to know

​This handbook is your primary resource on the Nebraska Medicaid program, including program regulations and service coverage requirements, as well as limitations, forms, billing requirements, and payment information.

Please review this handbook before providing services and requesting payment from Nebraska Medicaid, and share the handbook with personnel who perform referrals, authorization, coding, and claims submission for your office. 

Regulations

The following chapters under Regulation Title 417 Nebraska Medical Assistance  Program Services can be found on the Secretary Of State website:  ​

  • Chapter 1: Administration
  • Chapter 2: Provider Participation
  • Chapter 3: Payment for Medical Services
  • Chapter 4: Ambulance Services

​Appendices (Forms, Reports and Instructions)
​471-000-49​Claims Submission Table
​471-000-50​Standard Electronic Transaction Instructions
​471-000-53​Nebraska Medicaid Billing Instructions for Ambulance Services
​471-000-58​Example of Form CMS-1500, "Health Insurance Claim Form" (formerly HCFA-1500)
​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
​471-000-85​Explanation of Remittance Advice and Refund Requests Report
​471-000-87Example 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"
​471-000-122​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)