Nebraska Medicaid Program
Provider Information

Provider Enrollment

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

Need Assistance?

Medicaid Claims Customer Service
877-255-3092 (toll free) or 402-471-9128

Or Contact Provider Enrollment at:

UPDATED Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs

Information about federal exclusions, including databases of excluded individuals and entities, can be found on the Office of Inspector General’s website located at and at the System for Award Management website located at

How To Enroll in the Nebraska Medicaid Program

If you have been approached by an individual who is a recipient of Aged and Disabled Waiver services, Personal Assistance Service, and/or Developmental Disabilities services, the individual or their representative will need to contact their Service Coordinator or Social Services Worker requesting your enrollment as a provider.  Once contact has been made, you will receive a referral packet advising you of the steps to follow in the enrollment process.

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 15-51 Web Portal Implementation
Provider Bulletin 15-52 Group Member Registration
Provider Bulletin 15-53 Revalidation
Provider Bulletin 15-54 Maximus Information

Provider Bulletin 15-15 Provider Screening and Enrollment with Maximus

Provider Bulletin 15-48 Updated Provider Screening and Enrollment Materials

Provider Screening Risk Levels.

NEW The Maximus provider enrollment web portal will be implemented on December 1, 2015. Service Provider Agreements (MC-19) submitted on or after that date must be submitted to Maximus. Any service provider agreements received by Medicaid & Long-Term Care (MLTC) on or after that date will be forwarded to Maximus.

Providers choosing to complete enrollment activities through the web portal can do so here: beginning at 8:00 AM December 1st.

Providers are encouraged to enroll electronically in the Maximus web portal as described above.  Providers may still opt to enroll using the paper enrollment forms.  Please, see the instructions and list of available forms below.
New Provider Enrollment Paper Enrollment forms
    1. Print and complete the MC-19 (Instructions are on the MC-19-I) and applicable Medical Assistance Provider addendums per the list below by provider type. Provider Enrollment instructions continue below the list of addendums.

PDF Provider Agreement Forms


Service Provider Agreement-used by all provider types


Service Provider Agreement Instructions


PDF Additional Forms


Electronic Funds Transfer (EFT) *Required for new providers


​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.


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


PDF Service Provider Agreement Addendum Forms


Service Provider Addendum - HCB/NFOCUS only


Provider Release of Info/Felony-Misdemeanor Statement - HCB/NFOCUS only


Non-Emergency Transportation Addendum


New provider enrollment (continued)

  1. 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.

Completed paper enrollment packets can be sent to the Maximus email address below.

Providers who wish to update their enrollments, add services or make other changes, please see the Provider Educations & Training Resources on the Maximus web portal.

The Maximus web portal can be found at:

Maximus Customer Service can be reached toll free at: 1-844-374-5022 or

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