Nebraska Medicaid Program

Provider Information

Mental Health and Substance Abuse
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: PDFContacts Medicaid.

PDF Regulations

Chapter 1 Administration
Chapter 2 Provider Participation
Chapter 3 Payment for Medical Services
Chapter 20 Psychiatric Services for Individuals Age 21 and Older
Chapter 32 Mental Health and Substance Abuse Treatment Services for Children and Adolescents
Chapter 35 Rehabilitative Psychiatric Services

PDF Appendices (Forms, Reports and Instructions)

471-000-10 Instructions for Completing “Nebraska Medicaid Telehealth Patient Consent” Form
471-000-40 Form FA-20, “Cost Report of Psychiatric and Chemical Dependency Facilities for Medicaid Reimbursement”, and Completion Instructions
471-000-49 Claims Submission Table
471-000-50 Standard Electronic Transaction Instructions
471-000-51 Form CMS-1450 (UB-92), “Health Insurance Claim Form”, (Formerly HCFA-1450)
471-000-58 Example of Form CMS-1500, “Health Insurance Claim Form” (formerly HCFA-1500)
471-000-64 Billing Instructions for Mental Health and Substance Abuse Services
471-000-70 Nebraska Medicaid Billing Instructions for Medicare Crossover Claims
471-000-78 Nebraska Medicaid Form Locator Requirements for Form CMS-1450 (UB-92)
471-000-79 Form EA-160, “Record of Health Cost-Share of Cost-Medicaid Program” and Completion Instructions
471-000-85 Explanation of Remittance Advice and Refund Requests Report
471-000-87 Example of Form MC-2, “Electronic Attachment Control Number Form”
471-000-89 Form MC-14, “Confidential Report”, and Completion Instructions
471-000-90 Form MC-19, “Medical Assistance Provider Agreement” and Completion Instructions
471-000-91 Form MC-20, “Medicaid Hospital Provider Agreement”, and Completion Instructions
471-000-99 Medicaid Claim Adjustment and Refund Procedures
471-000-100 Form MCP575, “Casualty Insurance Policy Information Sheet”
471-000-102 Form MC-9, “Prior Authorization Document,” and Completion Instructions for IMD’s
471-000-122 Nebraska Health Connection: Listing of Plans and Vendors
471-000-123 Explanation of Nebraska Medicaid Eligibility Documents
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)
471-000-129 Explanation of Deleted Medicaid Claims and Medicaid Claims In Process over 30 Days Report (MCP564-DS)
471-000-211 Form MC-10, “Prior Authorization Document Adjustment”, and Completion Instructions
471-000-532 Nebraska Medicaid Practitioner Fee Schedule for Mental Health and Substance Abuse Services
471-000-540 Nebraska Medicaid Practitioner Fee Schedule for Injectables

PDF Provider Bulletins

Number Subject Date
​14-12 Billing Instructions Updated – CMS 1500 and CMS 1450 (UB04) ​03/05/14
​13-82 Medicaid ICD-10 Implementation Project December Update ​12/20/13
​13-66 Mental Health and Substance Use Copay Deductions ​10/08/13
​13-50 Timely Filing Requirement for all Medicaid Claims ​07/15/13
​13-38 Behavioral Health Evaluation & Management (E/M) Services in a Nursing Facility or PRTC ​07/30/13
​13-32 Behavioral Health is Expanding September 1, 2013 ​07/08/13
​13-20 Update to Medicaid Injectable Medication Fee Schedule ​03/08/13
​13-19 Award of Behavioral Health Substance and Substance Use Disorder—MCO Contract ​03/18/13
​13-06 Mental Health and Substance Use January 1, 2013 CPT Code Changes ​02/06/13
​12-73 Mental Health and Substance Use January 1, 2013 CPT Code Changes Update to Provider Bulletin 12-68 ​12/21/12
​12-70 Affordable Care Act Requirements for HIPAA Electronic Transactions ​12/20/12
​12-68 ​Mental Health and Substance Abuse, (MHSA), January 1,2013 CPT Code Changes ​12/18/12
​12-58 Provider Enrollment and Referring Providers ​11/14/12
​12-52 Provider Screening and Enrollment ​10/12/12
​12-43 Date Change in Timely Filing Requirements for All Medicaid Claims ​11/07/12
​12-35 180 Days Timely Filing for All Medicaid Claims ​07/02/12
​12-09 ​Initial ICD-10 Awareness ​02/07/12
​11-69 Medicaid Copayments for Mental Health and Substance Abuse Services ​10/12/11
​11-61 ​Billing for Multiple Services on the Same Service Date ​10/21/11
​11-36 Therapeutic Group Home Services, (ThGH) ​06/30/11
​11-35 ​Psychiatric Residential Treatment Facilities (PRTF) ​06/30/11


Claims for MHSA Services & the National Correct Coding Initiative 06/17/11


UPDATE Nebraska Medicaid Implementation of the National Correct Coding Initiative Edits



Nebraska Medicaid Implementation of the National Correct Coding Initiative Edits



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


Regulations for Assertive community Treatment (ACT) Services


Licensed Independent Mental Health Practitioners (LMHPs)


Procedure Code Change for the Annual Assessment by Psychologists


Crisis Services


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


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