Title 471 Nebraska Medical Assistance Program Services Appendix

 
3
Statutes & Regs
Operational
 
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Number Name
471-000-1Form EA-117, "Application for Assistance, and Completion Instructions
471-000-2Form DM-5, "Physician's Confidential Report" and Completion Instructions
471-000-3Form DM-5H, "Physician's Report on Hearing Loss" and Completion Instructions
471-000-4(Reserved)
471-000-5Instructions for Completing Form DM-5-DD-LTC, "Long Term Care Evaluation for Intermediate Care Facilities for the Individuals with Developmental Disabilities"
471-000-6 through 8(Reserved)
471-000-9Form DM-12, "Social Study," and Completion Instructions
471-000-10Instructions for Completing "Nebraska Medicaid Telehealth Patient Consent" Form
471-000-11Nursing Facility Administrator Compensation Maximums 
471-000-12 through 15(Reserved)
471-000-16Instructions for Completing Form DM-28-MR, "Intermediate Care Facility for Mentally Retarded Utilization Review"
471-000-17 through 37(Reserved)
471-000-38Form EPSDT-5, "Health Check Plan of Care", and Completion Instructions
471-000-39Dental Periodicity Schedule for Children
471-000-40Form FA-20, "Cost Report of Psychiatric and Chemical Dependency Facilities for Medicaid Reimbursement", and Completion Instructions
471-000-41Form FA-66, “Long-Term Care Cost Report" and Instructions
471-000-42  Form FA-66 ICF/DD, “Long-Term Care Cost Report Supplement" and Instructions
471-000-43 through 44(Reserved)
471-000-45Instructions for Completing Form MC-75-7, "MDS Section S"
471-000-46 through 48 (Reserved)
471-000-49Claims Submission Table  
471-000-50Standard Electronic Transaction Instructions  
471-000-51Form CMS-1450 (UB-04), "Health Insurance Claim Form", (Formerly HCFA-1450)
471-000-52Billing Instructions for Ambulatory Surgical Center (ASC) Services
471-000-53Billing Instructions for Ambulance Services
471-000-54Billing Instructions for Chiropractic Services
471-000-55Billing Instructions for Durable Medical Equipment, Medical Supplies, Orthotics and  Prosthetics
471-000-56Billing Instructions for Hearing Aid Services
471-000-57Billing Instructions for Home Health Agency Services
471-000-58Form CMS-1500, "Health Insurance Claim Form"
471-000-59Nebraska Medicaid Billing Instructions for Completing Form MC-82N, "Private Duty Nurse Claim Form" for Private Duty Nursing Services
471-000-60Instructions for Completing Form MC-82, "Personal Care Aide Claim Form"
471-000-61Billing Instructions for Physical Therapy, Speech Pathology and Audiology Services, and Occupational Therapy
471-000-62Billing Instructions for Physician, Laboratory, and Ambulatory Surgical Center (ASC) Services
471-000-63Billing Instructions for Podiatry Services
471-000-64Billing Instructions for Mental Health and Substance Abuse Services
471-000-65Billing Instructions for Visual Care Services
471-000-66Example of Form HCFA-1539, "Medicare/Medicaid Certification and Transmittal"
471-000-67Form MS-81, "Certification and Plan of Care for Private-Duty Nursing", and Completion Instructions
471-000-68Form IM-8, "Notice of Finding", and Completion Instructions
471-000-69Instructions for Completing Form MS-82, "Adult Day Care Assessment/Authorization"
471-000-70Billing Instructions for Medicare Crossover Claims
471-000-71Nebraska Medicaid Long-Term Care UB-04 Billing Instructions for Nursing Facility, ICF/MR. Assisted Living - Waiver, Hospital Swing Bed and Hospice in Nursing Facility or ICF/MR (ICF/ID) Providers
471-000-72Prior Authorization Dollar Limits for Dental Services
471-000-73Form MS-6, "Ambulatory Room and Board Agreement", and Completion Instructions
471-000-74Instructions for Completing Form MC-39, "Personal Assistance Services Provider Time Sheet"
471-000-75Nebraska Medicaid Billing Instructions for Completing Form MC-82-AD, "Adult Day Care nursing/Aide Services Claim Form" for Private Duty Nursing or Personal Assistance Services in Adult Day Care Centers
471-000-76Billing Instructions for Federally Qualified Health Center Services
471-000-77Billing Instructions for Rural Health Clinic Services
471-000-78Nebraska Medicaid Form Locator Requirements for Form CMS-1450 (UB-04)
471-000-79Form EA-160, "Record of Health Cost - Share of Cost - Medicaid Program", and Completion Instructions
471-000-80Nebraska Medicaid Long-Term Care UB-04 Billing Instructions for Durable Medical Equipment (DME) submitted by Nursing Facilities (NF's) and Intermediate Care Facilities (ICF's)
471-000-81Nebraska Medicaid Billing Instructions for Hospice Services
471-000-82(Reserved)
471-000-83Billing Instructions for Hospital Services
471-000-84Form MC-6, "Physician's Certification Form", and Completion Instructions
471-000-85Explanation of Remittance Advice and Refund Requests Report
471-000-86Example of Form MC-38, "Notice of Lock-In Finding"
471-000-87Example of Form MC-2, "Electronic Attachment Control Number Form"
471-000-88Nebraska Medicaid Dental Program Completion Instructions for the 2012 ADA Dental Claim Form
471-000-89Form MC-14, "Confidential Report", and Completion Instructions
471-000-90Form MC-19, "Medical Assistance Provider Agreement", and Completion Instructions
471-000-91Form MC-20, "Medicaid Hospital Provider Agreement", and Completion Instructions
471-000-92Instructions for Completing Form MC-37, "Home Care Time Sheet"
471-000-93Form MC-66 "Client Choice of Restricted Services (Lock-In) Provider Agreement", and Completion Instructions
471-000-94Instructions for Completing Form MC-84, "Personal Care Aide Provider Check List"
471-000-95Instructions for Completing Form MC-73, "Personal Care Services - Care Plan"
471-000-96 (Reserved)
471-000-97Instructions for Completing Form HHS-100 "Private Duty" Nursing Notes
471-000-98Nebraska Ownership/Controlling Interest and Conviction Disclosure" and Completion Instructions
471-000-99Form MC-11D, "Return of Warrant", and Medicaid Claim Adjustments and Refund Procedures
471-000-100Form MCP575, "Casualty Insurance Policy Information Sheet"
471-000-101Explanation of Form MC-85, "Supplemental Explanation of  Medicaid Benefits"
471-000-102 (Reserved)
471-000-103Form HHS-6, "Notice of Action," and Completion Instructions
471-000-104 through 105 (Reserved)
471-000-106Form MILTC-4B, "Provider Authorization Notice," and Completion Instructions
471-000-107Form MILTC-4D, "Physician/RN Statement for Health Maintenance Activities," and Completion Instructions
471-000-108Form HHS-4C, "Provider Notice" and Completion Instructions
471-000-109Form MMS-100, "Sterilization Consent Form", and Completion Instructions
471-000-110Form MMS-101, "Informed Consent for Hysterectomies", and Completion Instructions
471-000-111Form MS-44, "Hospice Prior Authorization Request" and Completion Instructions - (See 471-000-11 for Nursing Facility Administrator Compensation Maximums)
471-000-112IRS Form 2678, "Employer Appointment of Agent," and Completion Instructions
471-000-113 through 121 (Reserved)
471-000-122Heritage Health Managed Care: Listing of Plans and Vendors
471-000-123Explanation of Nebraska Medicaid Eligibility Documents
471-000-124Instructions for Using the Nebraska Medicaid Eligibility System (NMES)
471-000-125(Reserved)
471-000-126Procedure Codes Subject to Copayment Requirements
471-000-127Instructions for Explanation of Deleted Medicaid Claims Weekly Report (MCP564-D)
471-000-128Instructions for Explanations of Medicaid Claims in Process Over 30 Days Report (MCP564-S)
471-000-129Instructions for Explanation of Deleted Medicaid Claims and Medicaid Claims in Process Over 30 Days Report (MCP564-DS)
471-000-130 through 201(Reserved)
471-000-202Income Levels for Medical Assistance for Presumptive Eligibility for Pregnant Women
471-000-203Instructions for Completing Form MC-9NF, "Authorization for Facility Care"
471-000-204(Reserved)
471-000-205Form MC-9HA, "Prior Authorization Document for Hearing Aids", and Completion Instructions
471-000-206Form MS-77, "Request for Prior Authorization," and Completion Instructions
471-000-207Instructions for Completing Form MS-78, "Augmentative Communication Device Selection Report"
471-000-208Form MS-79, "Wheelchairs and Wheelchair Seating System Equipment Selection Report," and Completion Instructions
471-000-209Form MS-80, "Air Fluidized and Low Air Loss Bed Certification of Medical Necessity," and Completion Instructions
471-000-210 through 219(Reserved)
471-000-220Instructions for Completing Form DSS-14AD, "Functional Criteria"
471-000-221 through 229(Reserved)
471-000-230Instructions for Completing Form MC-OBRA-8, "Authorization for Release of Information"
471-000-231 through 302(Reserved)
 
471-000-303Form MS-91, "Presumptive Application for Pregnant Women"
471-000-304 through 405(Reserved)
471-000-406 Orthodontic Diagnostic Score Sheet and Other Information
471-000-407 through 408(Reserved)
471-000-409Ambulatory Surgical Center Rates
471-000-410Free Standing Birth Centers
471-000-411Pediatric Feeding Clinics
471-000-412 through 502(Reserved)
471-000-503Nebraska Medicaid Fee Schedule for Non-Emergency Transportation (NET) Services
471-000-504Nebraska Medicaid Practitioner Fee Schedule for Ambulance Services
471-000-505Nebraska Medicaid Practitioner Fee Schedule for Chiropractic Services
471-000-506Nebraska Medicaid Practitioner Fee Schedule for Dental Services
471-000-507Nebraska Medicaid Practitioner Fee Schedule for Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics
471-000-508Nebraska Medicaid Practitioner Fee Schedule for Hearing Aid Services
471-000-509Nebraska Medicaid Home Health Agency Fee Schedule
471-000-510 through 512 (Reserved)
471-000-513Nebraska Medicaid RN/LPN Fee Schedule
471-000-514(Reserved)
471-000-515Nebraska Medicaid Personal Care Aide Fee Schedule
471-000-516(Reserved)
471-000-517Nebraska Medicaid Practitioner Fee Schedule for Physical Therapy and Occupational Therapy
471-000-518Nebraska Medicaid Practitioner Fee Schedule for Physician Services
471-000-519Nebraska Medicaid Practitioner Fee Schedule for Podiatry Services
471-000-520Clinical Lab Fee Schedule
471-000-521Anesthesia Fee Schedule
471-000-522Enhanced Payments to Primary Care Providers
471-000-523Nebraska Medicaid Practitioner Fee Schedule for Speech Pathology and Audiology
471-000-524Nebraska Medicaid Practitioner Fee Schedule for Visual Care Services
471-000-525 through 531(Reserved)
471-000-532Nebraska Medicaid Practitioner Fee Schedule for Mental Health and Substance Abuse Services
471-000-533Nebraska Medicaid Practitioner Fee Schedule for HEALTH CHECK Services  
471-000-534 through 535(Reserved)
471-000-536Nebraska Medicaid Hospice Fee Schedule
471-000-537 through 539(Reserved)
471-000-540Nebraska Medicaid Practitioner Fee Schedule for Injectables
471-000-541Information on Site-of-Services-Differential