Nebraska Medicaid Program

Provider Information

ICF/DD 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 31 Services in Intermediate Care Facilities for the  Intellectual disability (ICF/DD’s)
Chapter 36 Hospice Services

PDF Appendices (Forms, Reports and Instructions)

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
471-000-5 Instructions for Completing Form DM-5-DD-LTC, “Long Term Care Evaluation for Intermediate Care Facilities for Persons w/Developmental Disabilities”
471-000-13 Instructions for Completing Form DM-27M, “ICF Utilization Review Minutes”
471-000-16 Instructions for Completing Form DM-28-MR, “Intermediate Care Facility for Persons w/Developmental Disabilities Utilization Review”
471-000-19 Form DM-27ICF-S, “ICF/DD Annual Onsite Review Summary Report,” and Completion Instructions
471-000-28 Instructions for Completing Form ASD-100, “De-Institutionalization Referral”
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 Persons w/Developmental Disabilities Cost Report Supplement”
471-000-49 Claims Submission Table
471-000-50 Standard Electronic Transaction Instructions
471-000-68 Form IM-8, “Notice of Finding”, and Completion Instructions
471-000-79 Form EA-160, "Record of Health Cost - Share of Cost - Medicaid Program", and Completion Instructions
471-000-80 ​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 )
471-000-82 Instructions for Completing Turnaround MC-4, “Long Term Care Facility Turnaround Billing Document”
471-000-85 Explanation of Remittance Advice and Refund Requests Report
471-000-87 Example of Form MC-2, "Electronic Attachment Control Number Form"
471-000-90 ​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)
471-000-127 Explanation of Deleted Medicaid Claims Weekly Report (MCP564-D)
471-000-128 Explanation of Medicaid Claims in Process Over 30 Days Report (MCP564-S)
471-000-203 Instructions for Completing Form MC-9NF, “Prior Authorization for Nursing Facility Care”
471-000-211 Form MC-10, “Prior Authorization Document Adjustment”, and Completion Instructions

PDF Provider Bulletins

Number Subject Date
​14-12 Billing Instructions Updated – CMS 1500 and CMS 1450 (UB04) ​03/05/14
​13-50 ​Timely Filing Requirement for all Medicaid Claims ​07/15/13
​12-09 ​Initial ICD-10 Awareness ​02/07/12
11-56

Update on Turnaround Billing

09/15/11
11-25

Elimination of Turnaround Billing Document

05/20/11
11-13

UPDATE Nebraska Medicaid Implementation of the National Correct Coding Initiative Edits

02/11/11
10-39

Nebraska Medicaid Implementation of the National Correct Coding Initiative Edits

09/20/10
09-02

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

02/04/09
08-25

Revision to NAC 471 Appendix 471-000-82 Instructions for Completing Turnaround MC-4 "Long Term Care Facility Turnaround Billing Document"

06/25/08
08-12

DHHS Website Email Notification Feature, Online Provider Handbooks and Provider Bulletins, Electronic Claims, Funds Transfer and Other Options

05/12/08
08-06

Tamper-Resistant Prescription Pads for the Nebraska Medicaid Pharmacy Program (Revised)

03/14/08
07-20

Tamper-Resistant Prescription Pads for the Nebraska Medicaid (Rescind effective 03/14/08)

09/05/07
07-10

New Medicaid Claim Reports – New Process for Reporting Deleted Medicaid Claims

05/09/07
07-07

Clarification of Facility Obligation to Reimburse for Nurse Aide Training and Competency Evaluation Program (NATCEP) Costs

02/26/07

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

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