Title 471 -- Nebraska Medical Assistance Program Services

Appendix

Number Name
471-000-1 Form EA-117, "Application for Assistance, and Completion Instructions
471-000-2 Form DM-5, "Physician's Confidential Report" and Completion Instructions
471-000-3  Form DM-5H, "Physician's Report on Hearing Loss" and Completion Instructions
471-000-4 (Reserved)
471-000-5 Instructions for Completing Form DM-5-MR-LTC, "Long  Term Care Evaluation for Intermediate Care Facilities for the Mentally Retarded"
471-000-6 Instructions for Completing Form DM-5R, "Disability Report"
471-000-7  (Reserved)
471-000-8  (Reserved)
471-000-9   Form DM-12, "Social Study," and Completion Instructions
471-000-10 Instructions for Completing "Nebraska Medicaid Telehealth Patient Consent" Form
471-000-11 Nursing Facility Administrator Compensation Maximums 
471-000-12 (Reserved)
471-000-13  Instructions for Completing Form DM-27M, "ICF/MR Utilization Review Minutes"
471-000-14 and 15  (Reserved)
471-000-16    Instructions for Completing Form DM-28-MR, "Intermediate Care Facility for Mentally Retarded Utilization Review"
471-000-17 and 18 (Reserved)
471-000-19    Form DM-27MR-S, "ICF/MR Annual Onsite Review  Summary Report," and Completion Instructions
471-000-20   (Reserved)
471-000-21 Form DSS-4, "Case Information Summary"
471-000-22 
   through 27
(Reserved)
471-000-28   

Instructions for Completing Form ASD-100, "De-Institutionalization Referral"

471-000-29
   through 37
(Reserved)
471-000-38    

Form EPSDT-5, "Health Check Plan of Care", and Completion Instructions

471-000-39 Dental Periodicity Schedule for Children
471-000-40 Form FA-20, "Cost Report of Psychiatric and Chemical Dependency Facilities for Medicaid Reimbursement", and Completion Instructions
471-000-41 Form 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)
471-000-45 Instructions for Completing Form MC-75-7, "MDS Section S"
471-000-46
  through 48
(Reserved)
471-000-49  Claims Submission Table  
471-000-50 Standard Electronic Transaction Instructions  
471-000-51 Form CMS-1450 (UB-04), "Health Insurance Claim Form", (Formerly HCFA-1450)
471-000-52 Billing Instructions for Ambulatory Surgical Center (ASC) Services
471-000-53 Billing Instructions for Ambulance Services
471-000-54  Billing Instructions for Chiropractic Services
471-000-55  Billing Instructions for Durable Medical Equipment, Medical Supplies, Orthotics and  Prosthetics
471-000-56 Billing Instructions for Hearing Aid Services
471-000-57  Billing Instructions for Home Health Agency Services
471-000-58  Form CMS-1500, "Health Insurance Claim Form"
471-000-59 Form MC-82N, "Private Duty Nurse Claim Form", and Completion Instructions
471-000-60 Instructions for Completing Form MC-82, "Personal Care Aide Claim Form"
471-000-61 Billing Instructions for Physical Therapy, Speech Pathology and Audiology Services, and Occupational Therapy
471-000-62 Billing Instructions for Physician, Laboratory, and Ambulatory Surgical Center (ASC) Services
471-000-63 Billing Instructions for Podiatry Services
471-000-64   Billing Instructions for Mental Health and Substance Abuse Services
471-000-65 Billing Instructions for Visual Care Services
471-000-66 Example of Form HCFA-1539, "Medicare/Medicaid Certification and Transmittal"
471-000-67  Form MS-81, "Certification and Plan of Care for Private-Duty Nursing", and Completion Instructions
471-000-68 Form IM-8, "Notice of Finding", and Completion Instructions
471-000-69  Instructions for Completing Form MS-82, "Adult Day Care Assessment/Authorization"
471-000-70 Billing Instructions for Medicare Crossover Claims
471-000-71 Nebraska 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
471-000-72 Prior Authorization Dollar Limits for Dental Services
471-000-73 Form MS-6, "Ambulatory Room and Board Agreement", and Completion Instructions
471-000-74 Instructions for Completing Form MC-39, "Personal Assistance Services Provider Time Sheet"
471-000-75 Nebraska 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
471-000-76 Billing Instructions for Federally Qualified Health Center Services
471-000-77 Billing Instructions for Rural Health Clinic Services
471-000-78 Nebraska Medicaid Form Locator Requirements for Form CMS-1450 (UB-04)
471-000-79 Form EA-160, "Record of Health Cost - Share of Cost - Medicaid Program", and Completion Instructions
471-000-80 Nebraska 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)
471-000-81   Nebraska Medicaid Billing Instructions for Hospice Services
471-000-82 (Reserved)
471-000-83 Billing Instructions for Hospital Services
471-000-84  Form MC-6, "Physician's Certification Form", and Completion Instructions
471-000-85 Explanation of Remittance Advice and Refund Requests Report
471-000-86 Example of Form MC-38, "Notice of Lock-In Finding"
471-000-87 Example of Form MC-2, "Electronic Attachment Control Number Form"
471-000-88 Nebraska Medicaid Dental Program Completion Instructions for the 2012 ADA Dental Claim Forms
471-000-89  Form MC-14, "Confidential Report", and Completion Instructions
471-000-90 Form MC-19, "Medical Assistance Provider Agreement", and Completion Instructions
471-000-91 Form MC-20, "Medicaid Hospital Provider Agreement", and Completion Instructions
471-000-92 Instructions for Completing Form MC-37, "Home Care Time Sheet"
471-000-93 Form MC-66 "Client Choice of Restricted Services (Lock-In) Provider Agreement", and Completion Instructions
471-000-94  Instructions for Completing Form MC-84, "Personal Care Aide Provider Check List"
471-000-95 Instructions for Completing Form MC-73, "Personal Care Services - Care Plan"
471-000-96  (Reserved)
471-000-97 Instructions for Completing Form HHS-100 "Private Duty" Nursing Notes
471-000-98 Nebraska Ownership/Controlling Interest and Conviction Disclosure” and Completion Instructions
471-000-99  Form MC-11D, "Return of Warrant", and Medicaid Claim Adjustments and Refund Procedures
471-000-100 Form MCP575, "Casualty Insurance Policy Information Sheet"
471-000-101 Explanation of Form MC-85, "Supplemental Explanation of  Medicaid Benefits"
471-000-102

(Reserved)

471-000-103 Form HHS-6, "Notice of Action," and Completion Instructions
471-000-104
   through 105
(Reserved)
471-000-106 Form MILTC-4B, "Provider Authorization Notice," and Completion Instructions
471-000-107 Form MILTC-4D, "Physician/RN Statement for Health Maintenance Activities," and Completion Instructions
471-000-108  Form HHS-4C, "Provider Notice" and Completion Instructions
471-000-109 Form MMS-100, "Sterilization Consent Form", and Completion Instructions
471-000-110 Form MMS-101, "Informed Consent for Hysterectomies", and Completion Instructions
471-000-111 Form MS-44, "Hospice Prior Authorization Request" - (See 471-000-11 for Nursing Facility Administrator Compensation Maximums)
471-000-112 IRS Form 2678, "Employer Appointment of Agent," and Completion Instructions
471-000-113 through 121 (Reserved)
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)
​471-000-125 ​(Reserved)
471-000-126 Procedure Codes Subject to Copayment Requirements
471-000-127 Instructions for Explanation of Deleted Medicaid Claims Weekly Report (MCP564-D)
471-000-128 Instructions for Explanations of Medicaid Claims in Process Over 30 Days Report (MCP564-S)
471-000-129 Instructions for Explanation of Deleted Medicaid Claims and Medicaid Claims in Process Over 30 Days Report (MCP564-DS)
471-000-130 through 200 (Reserved)
471-000-201 Instructions for Completing Form MC-9D, "Dental Treatment and Prior Authorization"
471-000-202 Income Levels for Medical Assistance for Presumptive Eligibility for Pregnant Women
471-000-203 Instructions for Completing Form MC-9NF, "Prior Authorization for Nursing Facility Care"
471-000-204 (Reserved)
471-000-205  Form MC-9S, "Prior Authorization Document for Hearing Aids", and Completion
471-000-206 Form MS-77, "Request for Prior Authorization," and Completion Instructions
471-000-207 Instructions for Completing Form MS-78, "Augmentative Communication Device Selection Report"
471-000-208 Form MS-79, "Wheelchairs and Wheelchair Seating System Equipment Selection Report," and Completion Instructions
471-000-209 Form MS-80, "Air Fluidized and Low Air Loss Bed Certification of Medical Necessity," and Completion Instructions
471-000-210 (Reserved)
471-000-211  Form MC-10, "Prior Authorization Document Adjustment", and Completion Instructions
471-000-212 through 219 (Reserved)
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)
471-000-223 Instructions for Completing Form DPI-OBRA1, "Identification Screen"
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
471-000-226 Instructions for Completing Form DPI-OBRA1a, "Categorical Determination and Exemption"
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"
471-000-232 (Reserved)
471-000-233  Qualified Mental Retardation Professional (42 CFR 483.430)  
471-000-234  Guidelines for Social History
471-000-235
through 300
(Reserved)
 
471-000-301  
through 302
(Reserved)
471-000-303

Form 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
and 408
(Reserved)
471-000-409   Ambulatory Surgery Center Rates

471-000-410

​Free Standing Birth Centers
471-000-411 ​Pediatric Feeding Clinics

471-000-412 through 502

(Reserved)
471-000-503  Nebraska Medicaid Fee Schedule for Non-Emergency Transportation (NET) Services
471-000-504  Nebraska Medicaid Practitioner Fee Schedule for Ambulance Services
471-000-505 Nebraska Medicaid Practitioner Fee Schedule for Chiropractic Services
471-000-506 Nebraska Medicaid Practitioner Fee Schedule for Dental Services
471-000-507 Nebraska Medicaid Practitioner Fee Schedule for Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics
471-000-508  Nebraska Medicaid Practitioner Fee Schedule for Hearing Aid Services
471-000-509  Nebraska Medicaid Home Health Agency Fee Schedule
471-000-510 through 512 (Reserved)
471-000-513 Nebraska Medicaid RN/LPN Fee Schedule
471-000-514 (Reserved)
471-000-515 Nebraska Medicaid Personal Care Aide Fee Schedule
471-000-516 (Reserved)
471-000-517 Nebraska Medicaid Practitioner Fee Schedule for Physical Therapy and Occupational Therapy
471-000-518 Nebraska Medicaid Practitioner Fee Schedule for Physician Services
471-000-519 Nebraska Medicaid Practitioner Fee Schedule for Podiatry Services
471-000-520 Clinical Lab Fee Schedule
471-000-521 Anesthesia Fee Schedule
471-000-522 Enhanced Payments to Primary Care Providers
471-000-523 Nebraska Medicaid Practitioner Fee Schedule for Speech Pathology and Audiology
471-000-524  Nebraska Medicaid Practitioner Fee Schedule for Visual Care Services
471-000-525 through 531 (Reserved)
471-000-532  Nebraska Medicaid Practitioner Fee Schedule for Mental Health and Substance Abuse Services
471-000-533  Nebraska Medicaid Practitioner Fee Schedule for HEALTH CHECK Services  
471-000-534 through 535 (Reserved)
471-000-536 Nebraska Medicaid Hospice Fee Schedule
471-000-537 through 539 (Reserved)
471-000-540 Nebraska Medicaid Practitioner Fee Schedule for Injectables
471-000-541 Information on Site-of-Services-Differential

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