Nebraska Medicaid Program
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: Contacts Medicaid
Appendices (Forms, Reports and Instructions)
||Instructions for Completing "Nebraska Medicaid Telehealth Patient Consent" Form|
||Dental Periodicity Schedule for Children|
||Claims Submission Table|
||Standard Electronic Transaction Instructions |
||Form EA-160, "Record of Health Cost - Share of Cost - Medicaid Program", and Completion Instructions|
||Explanation of Remittance Advice and Refund Requests Report|
||Example of Form MC-2, "Electronic Attachment Control Number Form"|
||Instructions for Completing 2012 ADA Dental Claim Form|
||Form MC-19, "Medical Assistance Provider Agreement" and Completion Instructions|
||Medicaid Claim Adjustment and Refund Procedures|
||Form MCP575, "Casualty Insurance Policy Information Sheet"|
||Nebraska Health Connection: Listing of Plans and Vendors|
||Explanation of Nebraska Medicaid Eligibility Documents|
||Instructions for Using the Nebraska Medicaid Eligibility System (NMES)|
||Procedure Codes Subject to Copayment Requirements|
||Explanation of Deleted Medicaid Claims Weekly Report (MCP564-D)|
||Explanation of Medicaid Claims in Process Over 30 Days Report (MCP564-S)|
||Orthodontic Diagnostic Score Sheet and Other Information|
||Nebraska Medicaid Practitioner Fee Schedule for Dental Services|
Go to Rules and Regulations and Provider Bulletins for all Medicaid regulations, appendices and bulletins.
Documents in PDF format require the use of Adobe Acrobat Reader which can be downloaded for free from Adobe Systems, Inc.