Nebraska Medicaid Program
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For more information about new screening and enrollment requirements, please visit our new webpage: Screening and Enrollment
Information about federal exclusions, including databases of excluded individuals and entities, can be found on the Office of Inspector General’s website located at http://oig.hhs.gov/exclusions/ 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
- Print and complete the applicable Medical Assistance Provider forms.
Provider Agreement Forms
|Service Provider Agreement-used by all provider types
|Service Provider Agreement Instructions
|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.
|Electronic Funds Transfer (EFT) *Required for new providers
|Instructions for completing the MS-84 Electronic Funds Transfer (EFT) form
|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.
|W-9 Tax Identification Number and Certification form (link to IRS website)
Service Provider Agreement Addendum Forms
|Service Provider Addendum
|Assisted Living Service Provider Addendum
|In-Home and License-Exempt Family Child Care Addendum
|Personal Emergency Response System Addendum
|Home Again Sponsor Addendum
|Chore/PAS Provider Addendum
|Adult Day Service Provider Addendum
|Meals Provider Addendum
|Respite Provider Addendum
|Provider Release of Info/Felony-Misdemeanor Statement
|Facility Provider Addendum
|Ambulatory Room and Board Addendum
|Pharmacy Provider Addendum
|Community Treatment Aide Addendum
|Group Therapy Addendum
(No Longer Required)
|Supervising Practitioner Addendum
|Scope of Practice Addendum
|Integrated Practice Addendum
|Program Outline Addendum
(No Longer Required)
|Mental Health/Substance Abuse Provider Addendum
(No Longer Required)
|Non-Emergency Transportation Addendum
|Hospital Provider Addendum
|Non-Specialized DD Service Provider Agree Addendum
|Non-Specialized DD Service Provider Agreement Addendum-Attachment #C
- Attach additional information.
- MS-84 – 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.
- Send the completed Service Provider Agreement form, addendum forms, MS-84, 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, MS-84, 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, MS-84, 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, MS-84, MLTC-62, W-9, and required attachments. Be sure to include your current Nebraska Medicaid provider number on the Provider Agreement form.
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