All Medicaid providers must enroll with the program. Medicaid provider enrollment is handled by Maximus.
Maximus Customer Service can be reached toll free at (844) 374-5022 or nebraskamedicaidPSE@maximus.com.
Completed paper enrollment packets can be sent to the email address above or mailed to:
Maximus Nebraska Medicaid Provider Enrollment P.O. Box 81890 Lincoln, Nebraska 68501
If you have been approached by an individual who is a recipient of Aged and Disabled Waiver services, Personal Assistance service, and/or Developmental Disabilities services, the individual or their representative will need to contact their service coordinator or social services worker requesting your enrollment as a provider. Once contact has been made, you will receive a referral packet advising you of the steps to follow in the enrollment process.
February 2, 2016 Policy regarding in-home service providers who are state employees: Policy
If you are a non-emergency transportation services provider interested in enrolling, contact Maximus at (844) 374-5022.
1. Print and complete the MC-19 (Instructions are on the MC-19-I) and applicable medical assistance provider addendums per the list below by provider type. Provider enrollment instructions continue below the list of addendums.
Forms are available at http://public-dhhs.ne.gov/Forms/Default.aspx
Provider Agreement Forms
Service Provider Agreement-used by all provider types: MC-19
Service Provider Agreement Instructions: MC-19-I
Electronic Funds Transfer (EFT) (Required for new providers): MS-84
Ownership/Controlling Interest and Conviction Disclosure (Required for enrollment and to report changes. Form is fillable. Complete on line, then print and mail to DHHS): MLTC-62
Authorization for Direct Deposit or US Bank ReliaCard (HCBS/NFOCUS providers only): FA-100
W-9 Tax Identification Number and Certification form: W-9
Service Provider Agreement Addendum Forms
Service Provider Addendum - HCB/NFOCUS only: MC-190
Provider Release of Info/Felony-Misdemeanor Statement - HCB/NFOCUS only: MC-199
Non-Emergency Transportation Addendum: MC-211
Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs: http://oig.hhs.gov/exclusions/files/sab-05092013.pdf
Information about federal exclusions, including databases of excluded individuals and entities, can be found on the Office of Inspector General's website located at http://oig.hhs.gov/exclusions/.
For information on tax-related questions, see below:
Tax-related Provider Questions
Medicaid providers have the option to receive their payment via Direct Deposit or ReliaCard. Disclosures related to ReliaCard payment election are provided through the link below: