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.

​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
    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

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