Nebraska Medicaid Program

Provider Information

Dental Provider Handbook
The links below comprise your Nebraska Medicaid Provider Handbook. This handbook is your primary resource for information about the Nebraska Medicaid Program, including program regulations, service coverage requirements and limitations, forms, billing requirements, and payment information.
Please review this handbook prior to providing services and requesting payment from Nebraska Medicaid and share it with personnel who perform referrals, authorization, coding and claims submission for your office.
If you have questions or comments about this information, contact the Medicaid Program Specialist for the type of service: PDF Contacts Medicaid.

PDF Regulations

Chapter 1 Administration
Chapter 2 Provider Participation
Chapter 3 Payment for Medical Services
Chapter 6 Dental Services

PDF Appendices (Forms, Reports and Instructions)

471-000-10 Instructions for Completing "Nebraska Medicaid Telehealth Patient Consent" Form
471-000-39 ​Dental Periodicity Schedule for Children
471-000-49 Claims Submission Table
471-000-50 Standard Electronic Transaction Instructions
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
471-000-87 Example of Form MC-2, "Electronic Attachment Control Number Form"
471-000-88 Instructions for Completing 2012 ADA Dental Claim 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)
471-000-126 Procedure Codes Subject to Copayment Requirements
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)
471-000-406 Orthodontic Diagnostic Score Sheet and Other Information

PDF Provider Bulletins

Number Subject Date
​17-16 Dental Managed Care Program; Contract Awarded ​06/13/17
​17-14 Dental Managed Care Program; Start Date Update ​04/13/17
​16-29 Dental Managed Care Program ​12/07/16
​15-36 ICD-10 and Dental Claims ​09/17/15
​15-13 Dental Hygienists and Procedure Codes ​04/06/15
​15-11 Suspension of Dental Carve In ​04/03/15
​14-12 Billing Instructions Updated – CMS 1500 and CMS 1450 (UB04) ​03/05/14
​13-82 Medicaid ICD-10 Implementation Project December 2013 Update ​12/20/13
​13-51 Affordable Care Act Administrative Simplification (AS) Requirements for HIPAA Electronic Transactions: Eligibility for a Health Plan (270/271) and Health Care Claim Status (276/277) ​07/19/13
​13-50 Timely Filing Requirement for all Medicaid Claims ​07/15/13
​13-47 American Dental Association (ADA) Claim Form 2012 ​07/18/13
​13-33 Prior authorization for root canals ​06/06/13
​12-62 New Dental Procedure Code ​12/06/12
​12-52 Provider Screening and Enrollment ​10/12/12
​12-09 Initial ICD-10 Awareness ​02/07/12

UPDATE Nebraska Medicaid Implementation of the National Correct Coding Initiative Edits


Nebraska Medicaid Implementation of the National Correct Coding Initiative Edits


Adult Dental Emergencies


Provider responsibility to screen employees and contractors for HHS-OIG exclusion status


$1000 Annual Dental Benefit Limit for Adults


Go to Rules and Regulations and Provider Bulletins for all Medicaid regulations, appendices and bulletins.

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