Nebraska Medicaid Program

Provider Information

Personal Assistance Services 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 15 Personal Assistance Services

PDF Appendices (Forms, Reports and Instructions)

471-000-60 Instructions for Completion of Form HHS-5N, “N-FOCUS Health and Human Services Billing Document”
​471-000-74 ​Appendix 471-000-74 Instructions for Completing Form MC-39
471-000-94 Instructions for Completing Form MC-84, “Personal Assistance Provider Check List”
471-000-95 “Service Needs Assessment/Plan”
471-000-105 Instructions for Completing Form MILTC-9, "Service Provider Agreement"
471-000-106 “Provider Authorization”
471-000-107 Instructions for Completing Form MILTC-4D. "Physician/RN Statement for Health Maintenance Activities"
471-000-108 “Provider Authorization Update”
471-000-112 Instructions for Completing Form IRS-2678, "Employer Appointment of Agent"
471-000-123 Explanation of Nebraska Medicaid Eligibility Documents
471-000-515 Nebraska Medicaid Personal Assistance Services Rate Listing

PDF Provider Bulletins




​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
11-55 NEW Personal Assistance Services Provider Timesheet 09/19/11
11-32 FY2012 Nebraska Medicaid Fee Schedule for Personal Assistance Services 06/15/11
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
10-27 Personal Assistance Services Provider Rate Increase 07/01/10
09-18 Personal Assistance Services Provider Rate Increase 06/29/09
09-02 Provider responsibility to screen employees and contractors for HHS-OIG exclusion status 02/04/09
08-12 DHHS Website Email Notification Feature, Online Provider Handbooks and Provider Bulletins, Electronic Claims, Funds Transfer and Other Options 05/12/08

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

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