Nebraska Medicaid Program
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For more information about new screening and enrollment requirements, please visit our new webpage: Screening and Enrollment
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 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
|Service Provider Agreement-used by all provider types
|Service Provider Agreement Instructions
|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 - HCB/NFOCUS only
|Provider Release of Info/Felony-Misdemeanor Statement - HCB/NFOCUS only
|Non-Emergency Transportation Addendum
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.