Nebraska Medicaid Program
Federally Qualified Health Center 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|
||Claims Submission Table|
||Standard Electronic Transaction Instructions |
||Form CMS-1450 (UB-92), “Health Insurance Claim Form”, (Formerly HCFA-1450)|
||Example of Form CMS-1500, "Health Insurance Claim Form" (formerly HCFA-1500)|
||Billing Instructions for Physician, Laboratory, and Ambulatory Surgical Center (ASC) Services|
||Nebraska Medicaid Billing Instructions for Medicare Crossover Claims|
||Billing Instructions for Federally Qualified Health Center Services|
||Nebraska Medicaid Form Locator Requirements for Form CMS-1450 (UB-92)|
||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"|
||Form MC-19, "Medical Assistance Provider Agreement" and Completion Instructions|
||Medicaid Claim Adjustment and Refund Procedures|
||Form MCP575, "Casualty Insurance Policy Information Sheet"|
||Explanation of Form PDS-38B, "Nebraska Health Connection ID Document"|
||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)|
||Explanation of Deleted Medicaid Claims and Medicaid Claims In Process over 30 Days Report (MCP564-DS)|
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 dowloaded for free from Adobe Systems, Inc.