Nebraska Medicaid Program

Provider Information

Physician/Laboratory 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 18 Physicians' Services
Chapter 33 Health Checks and Treatment Services for Conditions Disclosed during Health Checks (EPSDT)

PDF Appendices (Forms, Reports and Instructions)

471-000-2 Form DM-5, “Physician’s Confidential Report” and Completion Instructions
471-000-10 Instructions for Completing “Nebraska Medicaid Telehealth Patient Consent” Form
471-000-38 Form EPSDT-5, “Health Check Plan of Care”, and Completion Instructions
471-000-49 Claims Submission Table
471-000-50 Standard Electronic Transaction Instructions
471-000-58 Example of Form CMS-1500, “Health Insurance Claim Form” (formerly HCFA-1500)
471-000-62 Billing Instructions for Physician, Laboratory, and Ambulatory Surgical Center (ASC) Services
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
471-000-87 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”
471-000-109 Form MMS-100, “Sterilization Consent Form”, and Completion Instructions
471-000-110 Form MMS-101, “Informed Consent for Hysterectomies”, and Completion Instructions
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)
471-000-518 Nebraska Medicaid Practitioner Fee Schedule for Physician Services
471-000-520 Nebraska Medicaid Practitioner Fee Schedule for Clinical Lab
471-000-533 Nebraska Medicaid Practitioner Fee Schedule for HEALTH CHECK 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
​14-04 Immediate enrollment into Managed Care ​01/14/14
​13-82 ​​Medicaid ICD-10 Implementation Project December 2013 Update ​12/20/13
​13-77 Medicaid ICD-10 Implementation Project November 2013 Update ​11/26/13
​13-75 ​​Implementation of Revised CMS 1500 Claim Form / Version 02/12 ​11/14/13
​13-71 Medicaid ICD-10 Implementation Project October 2013 Update ​10/21/13
​13-67 Medicaid ICD-10 Implementation Project September 2013 Update ​09/25/13
​13-58 Medicaid ICD-10 Implementation Project August 2013 Update ​08/30/13
​13-52 Medicaid ICD-10 Implementation Project July 2013 Update ​08/05/13
​13-51 ​07/19/13
​13-64 Seasonal Influenza Vaccine 2013/2014 Update ​09/24/13
​13-50 Timely Filing Requirement for all Medicaid Claims ​07/15/13
​12-47 2012/2013 Medicaid RSV Infection Prophylaxis Update ​09/25/12
​12-09 ​Initial ICD-10 Awareness ​02/07/12

11-51

Medicaid Prior Authorization: Enzyme-Replacement Therapy (ERT) for Lysosomal Storage Disorders (Replaces Provider Bulletin 08-01) 09/20/11

11-50

Billing for Physician Administered Medications on the Same Date as an Office Visit 09/20/11

11-13

UPDATE Nebraska Medicaid Implementation of the National Correct Coding Initiative Edits

02/11/11

10-60

A. Coverage of Zyprexa Relprevv
B. Revised Risperdal Consta Authorization Requirements
C. End Prior Authorization of Certain Psychiatric Injectable Medications

12/15/10

10-54

Preferred Drug List

10/22/10

10-39

Nebraska Medicaid Implementation of the National Correct Coding Initiative Edits

09/20/10

10-26

Secure Residential Rehabilitation Services

07/01/10

10-22

July 1, 2010 Rate Increase

06/25/10

09-32

Seasonal Influenza Vaccine-2009/2010 Update

09/01/09
09-32

Seasonal Influenza Vaccine-2009/2010 Update

09/01/09
09-26

2009/2010 Medicaid RSV Infection Prophylaxis Update

08/20/09
09-16

Radiology Prior Authorization(s)

04/21/09
09-15

Physician Application of Fluoride Varnish

04/22/09
09-14

Coverage of Essure Sterilizations

06/26/09
09-04

Primary Care Case Management (PCCM) Referral/Authorization for Physician Services

02/25/09
09-02

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

02/04/09
08-39

Coverage of Tobacco Cessation Midrin Coverage

12/04/08
08-32

2008/2009 Medicaid RSV Infection Prophylaxis Update (Replaces Bulletin 07-26)

9/18/08

08-31

Influenza Vaccine - 2008/2009 Update (Replaces Bulletin 07-24)

09/18/08

08-24

Fee Schedule Update

06/26/08
08-13

1.) Elimination of Claims Attachment Requirements for Certain Codes.
2.) Change of Coding Requirements for IUD Billing.

05/12/08
08-12

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

05/12/08
08-08

Fee Schedule Rate Changes for Radiology Services

03/10/08
08-06

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

03/14/08
08-03

National Drug Code (NDC) Requirements for Physician Administered Medication

01/31/08
08-01

Medicaid Prior Authorization:  Enzyme-Replacement Therapy (ERT) for Lysosomal Storage Disorder (Rescind effective 09/20/11)

01/14/08
07-26

2007/2008 Medicaid RSV Infection Prophlaxis Update (Rescind effective 09/17/08)

10/12/07
07-24

Influenza Vaccine - 2007/2008 Update (Rescind effective 09/18/08)

10/05/07
07-23

Peer Review Organization

10/09/07
07-20

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

09/05/07
07-11

Growth Hormone Criteria

05/15/07
07-10

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

05/09/07
07-05

Medicaid Coverage for Human Papillomarvirus (HPV) Vaccine

03/08/07
07-04

Medicaid Reimbursement for End State Renal Disease (ESRD) Laboratory Tests

02/13/07
07-01

Correct Claim Submission for Frames and Lenses

01/03/07
06-15

Medicaid Coverage for Rotavirus Vaccine

06/19/06
06-03

Medicaid Coverage for Hepatitis A Vaccine and Measles, Mumps, Rubella, and Varicella (MMRV) Vaccine

01/10/06
05-34

Polycarbonate Lenses

12/05/05
05-30

Medicaid Coverage of Meningococcal Conjugate Vaccine & Tetanus, Diphtheria, Acellular Pertussis Vaccine

10/20/05
05-22

Billing Instructions Revision for Physicians with Pathology Specialty

08/15/05
05-15

Eyeglass Replacement, Eye Examination, Vision Condition Codes, and Lens Tints

07/11/05
05-11

Radiology Contrast Coding – Q Codes

05/31/05
04-21

Risperdal Consta

10/21/04
04-04

Medicaid Coverage of Xolair®

03/24/04
03-27

Clarification for the use of CPT Procedure Codes 92225 and 92226

11/03/03

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

Documents in PDF PDF format require the use of Adobe Acrobat Reader which can be downloaded for free from Adobe Systems, Inc.