PicturesAgingMedicaid Waiver InitiativePress ReleasesSearch NEBRASKA MEDICAID PROGRAM Page Content Medicaid Program Home Medicaid Services Medicaid Reform Medical Assistance Advisory Committee Current Initiatives Contacts Medicaid Electronic Health Record (EHR) Incentive Program Medical Necessity Guideline and Criteria Provider Information Program Integrity CHIP Managed Care Pharmacy Services Rules and Regulations Medicaid State Plan Electronic Data Interchange Client Information Recent Web Updates Nebraska Medicaid ProgramProvider Information Provider Enrollment Click to subscribe For more information about new screening and enrollment requirements, please visit our new webpage: Screening and Enrollment Need Assistance? Medicaid Claims Customer Service877-255-3092 (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 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 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. February 2, 2016 Policy regarding In-home Service Providers who are State Employees. If you are a non-emergency transportation services provider, contact IntelliRide, a non-emergency transportation services brokerage, at (844) 531-3783 to enroll. Number Subject Date 16-22 Provider Screening and Enrollment – Revalidation 09/21/16 16-18 Provider Screening and Enrollment – Retroactive Enrollment of Providers 07/19/16 16-17 Provider Screening and Enrollment – Ordering and Referring Practitioners 07/18/16 16-09 Provider Screening and Enrollment – Site Visits 2/03/16 15-57 Provider Screening and Enrollment – Implementation 12/01/15 15-54 Maximus Information 11/17/15 15-53 Revalidation 11/17/15 15-52 Group Member Registration 11/17/15 15-51 Web Portal Implementation 11/17/15 15-48 Updated Provider Screening and Enrollment Materials 10/08/15 15-15 Provider Screening and Enrollment 05/05/15 15-06 Provider Screening and Enrollment Project 02/18/15 12-67 Retroactive Enrollment of Providers 12/10/12 12-52 Provider Screening and Enrollment 10/12/12 12-36 Retroactive Enrollment of Providers 08/17/12 Provider Screening Risk Levels. New Provider Enrollment Paper Enrollment forms 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. Provider Agreement Forms Form Service Provider Agreement-used by all provider types MC-19 Service Provider Agreement Instructions MC-19-I Additional Forms Form 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 Service Provider Agreement Addendum Forms Form Service Provider Addendum - HCB/NFOCUS only MC-190 Provider Release of Info/Felony-Misdemeanor Statement - HCB/NFOCUS only MC-199 Non-Emergency Transportation Addendum MC-211 New provider enrollment (continued) 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: www.nebraskamedicaidproviderenrollment.com Maximus Customer Service can be reached toll free at: 1-844-374-5022 or nebraskamedicaidPSE@maximus.com Documents in PDF format require the use of Adobe Acrobat Reader which can be downloaded for free from Adobe Systems, Inc.