Nebraska Medicaid Program
Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics 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.
Appendices (Forms, Reports and Instructions)
||Claims Submission Table|
||Standard Electronic Transaction Instructions |
||Billing Instructions for Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics|
||Example of Form CMS-1500, "Health Insurance Claim Form" (formerly HCFA-1500)|
||Nebraska Medicaid Billing Instructions for Medicare Crossover Claims|
||Form EA-160, "Record of Health Cost - Share of Cost - Medicaid Program", and Completion Instructions|
||Nebraska Medicaid Long-Term Care UB-04 Billing Instructions for Durable Medical Equipment (DME) submitted by Nursing Facilities (NF’s) NFs and Intermediate Care Facilities (ICFs )|
||Explanation of Remittance Advice and Refund Requests Report|
||Example of Form MC-2, "Electronic Attachment Control Number 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)|
||Explanation of Deleted Medicaid Claims Weekly Report (MCP564-D)|
||Explanation of Medicaid Claims in Process Over 30 Days Report (MCP564-S)|
||Form MS-77, "Request for Prior Authorization," and Completion Instructions|
||Instructions for Completing Form MS-78, "Augmentative Communication Device Selection Report"|
||Form MS-79, "Wheelchairs and Wheelchair Seating System Equipment Selection Report," and Completion Instructions|
||Form MS-80, "Air Fluidized and Low Air Loss Bed Certification of Medical Necessity," and Completion Instructions|
||Nebraska Medicaid Practitioner Fee Schedule for Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics|
Go to Rules and Regulations and Provider Bulletins for all Medicaid regulations, appendices and bulletins.
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