Nebraska Medicaid Program

Provider Information

Pharmacy 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: PDFContact Medicaid.

PDF Regulations

Chapter 1 Administration
Chapter 2 Provider Participation
Chapter 3 Payment for Medical Services
Chapter 7 Durable Medical Equipment and Medical Supplies
Chapter 16 Pharmacy Services

PDF Appendices (Forms, Reports and Instructions)

471-000-49 Claims Submission Table
471-000-50 Standard Electronic Transaction Instructions
471-000-55 Billing Instructions for Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics
471-000-58 Example of Form CMS-1500, “Health Insurance Claim Form” (formerly HCFA-1500)
471-000-70 Nebraska Medicaid Billing Instructions for Medicare Crossover Claims
471-000-79 Form EA-160, “Record of Health Cost-Share of Cost-Medicaid Program” and Completion Instructions
471-000-84 Form MC-6, “Physician’s Certification Form”, and Completion Instructions
471-000-85 Explanation of Remittance Advice and Refund Requests Report
471-000-86 Example of Form MC-38, “Notice of Lock-In Finding”
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
471-000-93 Instructions for Completing Form MC-66, “Recipient Choice of Provider Agreement”
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)
471-000-126 Procedure Codes Subject to Copayment Requirements
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)
471-000-206 Form MS-77, “Request for Prior Authorization,” and Completion Instructions
471-000-207 Instructions for Completing Form MS-78, “Augmentative Communication Device Selection Report”
471-000-208 Form MS-79, “Wheelchairs and Wheelchair Seating System Equipment Selection Report,” and Completion Instructions
471-000-209 Form MS-80, “Air Fluidized and Low Air Loss Bed Certification of Medical Necessity,” and Completion Instructions
471-000-507 Nebraska Medicaid Practitioner Fee Schedule for Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics

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
11-13

UPDATE Nebraska Medicaid Implementation of the National Correct Coding Initiative Edits

02/11/11
10-54

Preferred Drug List

10/22/10
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
08-40

Medicaid Coverage of Tobacco Cessation, Omeprazole & Midrin

12/08/08
08-33

Tamper-Resistant Prescription Pads for the Nebraska Medicaid Pharmacy Program Update (Replaces Bulletin 08-06 Issued 03/14/08

09/17/08
08-23

Durable Medical Equipment (DME) Fee Schedule Rate Changes

07/01/08
08-14

Reimbursement for Wheelchairs Provided to Clients Residing in Nursing Facilities (Bulletin to DME Suppliers)

05/01/08
08-12

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

05/12/08
08-07

Fee Schedule Rate Changes for Oxygen Services

03/10/08
08-06

Tamper-Resistant Prescription Pads for the Nebraska Medicaid Pharmacy Program (Rescind effective 09/17/08)

03/14/08
07-27

Cough and Cold Covered Products

10/25/07
07-20

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

09/05/07
07-12

Hepatitis C PA Criteria, Byetta PA Form, Cox II Criteria

5/15/07
07-11

Growth Hormone Criteria

05/15/07
07-10

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

05/09/07
07-06

NPI, Prior Authorization, TPL, Byetta PA Form, New Drug PA Form

04/05/07
06-29

Quantity or High Dose Overrides

12/29/06
06-25

Change to Early Refill on Controlled Substances

09/28/06
06-24

Nutritional Supplementation

09/15/06
06-06

Eliminating Medicaid Coverage of Drugs for Sexual or Erectile Dysfunction; Medicare Part D

02/02/06
05-35

Implementation of Medicare Part D

12/14/05
05-24

Nutritional Supplement Claim Submission and Reimbursement

09/14/05
05-07

Reimbursement for Wheelchairs Provided to Clients Residing in Nursing Facilities (Bulletin to DME Suppliers) (Rescind effective 05/01/08)

05/22/05
04-21

Risperdal Consta

10/21/04
04-04

Medicaid Coverage of Xolair®

03/24/04

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

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