Nebraska Medicaid Program
ICF/MR 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)
||Form EA-117, “Application for Assistance, and Completion Instructions|
||Form DM-5, “Physician’s Confidential Report” and Completion Instructions|
||Instructions for Completing Form DM-5-MR-LTC, “Long Term Care Evaluation for Intermediate Care Facilities for the Mentally Retarded”|
||Instructions for Completing Form DM-27M, “ICF Utilization Review Minutes”|
||Instructions for Completing Form DM-28-MR, “Intermediate Care Facility for Mentally Retarded Utilization Review”|
||Form DM-27MR-S, “ICF/MR Annual Onsite Review Summary Report,” and Completion Instructions|
||Instructions for Completing Form ASD-100, “De-Institutionalization Referral”|
||Instructions for Completing Form FA-66, “Long Term Care Cost Report”|
||Instructions for Completing Form FA-66MR, “Intermediate Care Facilities for the Mentally Retarded Cost Report Supplement”|
||Claims Submission Table|
||Standard Electronic Transaction Instructions|
||Form IM-8, “Notice of Finding”, and Completion Instructions|
||Form EA-160, "Record of Health Cost - Share of Cost - Medicaid Program", and Completion Instructions|
||Instructions for Completing Turnaround MC-4, “Long Term Care Facility Turnaround Billing Document”|
||Explanation of Remittance Advice and Refund Requests Report|
||Example of Form MC-2, "Electronic Attachment Control Number Form"|
||Medicaid Claim Adjustment and Refund Procedures|
||Form MCP575, "Casualty Insurance Policy Information Sheet"|
||Instructions for Completing Form MC-81, “Medical Assistance Long Term Care Provider Agreement”|
||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)|
||Instructions for Completing Form MC-9NF, “Prior Authorization for Nursing Facility Care”|
||Form MC-10, “Prior Authorization Document Adjustment”, and Completion Instructions|
Go to Rules and Regulations and Provider Bulletins for all Medicaid regulations, appendices and bulletins.
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