Nebraska Medicaid Program
Provider Information

Provider Enrollment

Subscribe  Click to subscribe

For more information about new screening and enrollment requirements, please visit our new webpage:  Screening and Enrollment 

Need Assistance?

Medicaid Inquiry
877-255-3092 (toll free) or 402-471-9128

Or Contact Provider Enrollment at:
DHHS.MedicaidProviderEnrollment@Nebraska.gov

UPDATED Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs http://oig.hhs.gov/exclusions/files/sab-05092013.pdf
 

Information about federal exclusions, including databases of excluded individuals and entities, can be found on the Office of Inspector General’s website located at https://oig.hhs.gov/exclusions/index.asp and at the System for Award Management website located at https://www.sam.gov/portal/public/SAM/.

How To Enroll in the Nebraska Medicaid Program

If you are a Personal Assistance Service or Developmental Disabilities services provider, contact your local DHHS office to begin the enrollment process.

If you are a Medicaid Waiver services provider (Adult Day Health Care, Assisted Living Services, Childcare for Children with Disabilities, Home Care/Chore, Home-Delivered Meals, Independence Skills Management, Nutrition Services, Personal Emergency Response System, or Respite Care) contact the local Waiver office www.dhhs.ne.gov/hcs/services/Service-Coordination.htm to enroll.

If you are a non-emergency transportation services provider, contact IntelliRide, a non-emergency transportation services brokerage, at (844) 531-3783 to enroll.

Provider Bulletin 12-36 Retroactive Enrollment of Providers

Provider Bulletin 12-67 Retroactive Enrollment of Providers

  1. Print and complete the applicable Medical Assistance Provider forms.

PDF Provider Agreement Forms

Form

Service Provider Agreement-used by all provider types

MC-19

Service Provider Agreement Instructions

MC-19-I

PDF Additional Forms

Form

US Citizenship Attestation Form. EFFECTIVE with all MC-19s received on or after December 1, 2012, this attestation must be signed by all INDIVIDUAL providers wishing to enroll with Nebraska Medicaid. This form does not apply to group members, or to individuals enrolling solely as a prescribing, ordering, or referring practitioner unless enrolling as a solo practitioner under their own Medicaid provider ID.

Attestation English

Attestation Spanish

Electronic Funds Transfer (EFT) *Required for new providers

MS-84

​Instructions for completing the MS-84 Electronic Funds Transfer (EFT) form MS-84 Instructions
Ownership/Controlling Interest and Conviction Disclosure. Required for enrollment and to report changes. Form is fillable. Complete on line, then print and mail to DHHS.

MLTC-62

W-9 Tax Identification Number and Certification form (link to IRS website)

W-9

PDF Service Provider Agreement Addendum Forms

Form

Service Provider Addendum

MC-190

Assisted Living Service Provider Addendum

MC-191AD

In-Home and License-Exempt Family Child Care Addendum

MC-192AD

Personal Emergency Response System Addendum

MC-193AD

Home Again Sponsor Addendum

MC-194

Chore/PAS Provider Addendum

MC-195

Adult Day Service Provider Addendum

MC-196

Meals Provider Addendum

MC-197

Respite Provider Addendum

MC-198

Provider Release of Info/Felony-Misdemeanor Statement

MC-199

Facility Provider Addendum

MC-200

Ambulatory Room and Board Addendum

MC-201

Pharmacy Provider Addendum

MC-202

Community Treatment Aide Addendum

MC-203

Group Therapy Addendum

MC-204
(No Longer Required) 

Supervising Practitioner Addendum

MC-205

Scope of Practice Addendum

MC-206

Integrated Practice Addendum

MC-207

Program Outline Addendum

MC-208
(No Longer Required)

Mental Health/Substance Abuse Provider Addendum

MC-209
(No Longer Required)

MHCP Addendum

MC-210

Non-Emergency Transportation Addendum

MC-211

Hospital Provider Addendum

MC-212

Non-Specialized DD Service Provider Agree Addendum

MC-213

Non-Specialized DD Service Provider Agreement Addendum-Attachment #C

MC-214

  1. Attach additional information.
  • ACH – Required for all providers
  • MLTC-62 – Required for all providers
  • W-9 Tax Identification Number and Certification form - Required for all Providers
  • Copy of license – Required for all licensed provider types
  • Medicare/CNN CMS Certification Number, if applicable.
  1. Send the completed Service Provider Agreement form, addendum forms, ACH, MLTC-62, W-9, and required attachments to the following Email address: DHHS.MedicaidProviderEnrollment@nebraska.gov

Otherwise you may, Fax to: 402-742-2373

or mail the paperwork to the following via postal service:

Department of Health and Human Services
ATTN: Medicaid Provider Enrollment
P.O. Box 95026
Lincoln, NE 68509-5026

 

Keep Your Provider Agreement Current

  • Moving/Address Change: Fax (402-742-2373) or mail written notification. Include your old and new address and your current Nebraska Medicaid provider number in the letter.
  • Establishing To A New Location: Complete a new provider agreement form, addendum forms, ACH, MLTC-62, W-9, and required attachments for the new office. Each office location must have a separate Nebraska Medicaid provider number.
  • New Member Joining Your Group Practice: Complete a new provider agreement form, addendum forms, ACH, MLTC-62, W-9, and required attachments for the new practitioner. Be sure to include your current Nebraska Medicaid provider number on the form and indicate the requested effective date.
  • Member Leaving Your Group Practice: Fax (402-742-2373) or mail written notification. Include the name of the member, the date of departure, and your current Nebraska Medicaid provider number in the letter.
  • New Federal Tax ID Number (FTIN): Complete a new Provider Agreement form, addendum forms, ACH, MLTC-62, W-9, and required attachments. Be sure to include your current Nebraska Medicaid provider number on the Provider Agreement form.

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