DHHS Internet Website - Medicaid & Long-term Health Care

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 

How To Enroll in the Nebraska Medicaid Program

If you are a Personal Assistance Service or Developmental Disabilities services provider, contact your local DHHS office to begin the enrollment process.

If you are a Medicaid Waiver services provider (Adult Day Health Care, Assisted Living Services, Childcare for Children with Disabilities, Home Care/Chore, Home-Delivered Meals, Independence Skills Management, Nutrition Services, Personal Emergency Response System, or Respite Care) contact the local Waiver office www.dhhs.ne.gov/hcs/services/Service-Coordination.htm to enroll.

If you are a non-emergency transportation services provider contact AMR/Access2Care, a non-emergency transportation services brokerage, at 855-230-5353 to enroll.

1. Print and complete the applicable Medical Assistance Provider forms.

2. Attach additional information.

• ACH – 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.

3. Send the completed Service Provider Agreement form, addendum forms, ACH, MLTC-62, W-9, and required attachments to the following Email address: DHHS.MedicaidProviderEnrollment@nebraska.gov

Otherwise you may, Fax to: 402-742-2373

or mail the paperwork to the following via postal service:

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

 

Keep Your Provider Agreement Current

• Moving/Address Change: Fax (402-742-2373) or mail written notification. Include your old and new address and your current Nebraska Medicaid provider number in the letter.

• Expanding To A New Location: Complete a new provider agreement form for the new office. Each office location must have a separate Nebraska Medicaid provider number.

• New Member Joining Your Group Practice: Complete a new provider agreement form for the new practitioner. Be sure to include your current Nebraska Medicaid provider number on the form and indicate the requested effective date.

• Member Leaving Your Group Practice: Fax (402-742-2373) or mail written notification. 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, EFT form, Ownership Disclosure form, and required attachments.  Be sure to include your current Nebraska Medicaid provider number on the Provider Agreement form.

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