| 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 |
Example of Form DM-8, "IPR-Institutions for Mental Disease Ages 21 and Under" |
| 471-000-8 |
Example of Form DM-9, "IPR-Institutions for Mental Disease Ages 65 and Older" |
| 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 |
Instructions for Completing Form FA-66, "Long Term Care Cost Report" |
| 471-000-42 |
Instructions for Completing Form FA-66MR, "Intermediate Care Facilities for the Mentally Retarded Cost Report Supplement" |
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" (formerly HCFA-1500) |
| 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 |
(Reserved) |
| 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 2006, 2002, 1999 and 1994 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 |
Instructions for Completing Form MC-66, "Recipient Choice of Provider Agreement" |
| 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 |
Form MC-83, "Mental Health/Substance Abuse Treatment Planning Document for Outpatient Services", and Completion Instructions |
| 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 |
Form MC-9, "Prior Authorization Document," and Completion Instructions for IMD's |
| 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 Comensation 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 Instructions |
| 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 |
(Reserved) |
| 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 |