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:
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.

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: www.nebraskamedicaidproviderenrollment.com beginning at 8:00 AM December 1st.

 New Provider Enrollment
    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

Form

Service Provider Agreement-used by all provider types

NEW MC-19

Service Provider Agreement Instructions

NEW MC-19-I

PDF 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.

NEW MLTC-62

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

W-9

PDF Service Provider Agreement Addendum Forms

Form

Service Provider Addendum

MC-190

Provider Release of Info/Felony-Misdemeanor Statement

MC-199

Non-Emergency Transportation Addendum

MC-211


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.
  1. You may use one of the following methods to file all forms and written notifications:
Fax to: 402-742-2373

United States Postal Service:
Department of Health and Human Services
ATTN: Medicaid Provider Enrollment
P.O. Box 95026
Lincoln, NE 68509-5026

Existing provider revalidation

  1. Print and complete a new MC-19 and applicable provider addendum by provider type from the list above.

Required Only If Changes

  1. Submit a new W-9 only if your IRS EIN has changed
  2. Submit new MS-84 only if your ACH/EFT has changed
  3. Submit a new MLTC-62 only if your ownership

Keep Your Provider Agreement Current

  • Moving/Address Change: Written notification is required. Include your old and new address and your current Nebraska Medicaid provider number in the letter.
  • Establishing 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 MC-19 provider agreement form with members NPI.  Include a copy of the new member’s license.  Be sure to include your current Nebraska Medicaid provider number on the form and indicate the requested effective date.
  • Member Leaving Your Group Practice: Written notification is required. 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 and complete the applicable Medical Assistance Provider forms.

 You may use one of the following methods to file all forms and written notifications:

Fax to: 402-742-2373

United States Postal Service:
Department of Health and Human Services
ATTN: Medicaid Provider Enrollment
P.O. Box 95026
Lincoln, NE 68509-5026

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