Provider Information & Forms

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Lifespan Health
Public Health
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What would you like to do?

What you need to know

​Contracted Provider (doctors and clinic) Listing

Medicaid Expansion:  Heritage Health Adult expands Medicaid to lower income adults (age 19 to 64) who earn up to 138% of the federal poverty level. Nebraska Medicaid will begin accepting applications for HHA starting August 1, 2020. Benefits will begin on October 1, 2020.  For more information or to see if your patients are eligible please visit the Medicaid Expansion web site. 

Medicaid Expansion Toolkit: Heritage Health Adult (HHA) Resource Toolkit

 

Notice for Chrome, Firefox and Safari users

The "Email" submit button at the bottom of fillable forms does not work due to a known issue with Chrome, Firefox and Safari web browsers.  Please download the form, complete, save to your computer and email to: DHHS.EveryWomanMatters@nebraska.gov  


Provider Contract Manual, Fee Schedules and Income Guidelines

Women's and Men's Health Pro​vider Contract Manual

Women's and Men's Health Fee Schedule (2021-2022)
Women's and Men's Health Fee Schedule (2020-2021)

Income Eligibility Guidelines (2021-2022)

State Pap Plus Program Enrollment and Documentation Policy (January 2020)

Cholesterol Recommendations
Hypertension Recommendations

General Forms

Provider Materials Re-Order Form

Inflatable Colon Rental Information

Healthy Lifestyle Questionnaire
Healthy Lifestyle Questionnaire (Spanish)
Women Deemed Lost to Follow Up Form
Treatment Funds Request Form
Claim Status Form​
Payment Status Form
Mammography Order Form
Tobacco Free Nebraska Quitline Fax Referral​ 

Diagnostic Enrollment/Follow-Up and Treatment Forms

Diagnostic Presumptive Eligibility Checklist
2018-19 Diagnostic Reference Quick Guide

Breast Diagnostic Enrollment/Follow-Up Treatment
  English
  Spanish
  Breast Diagnostic Instructions

Breast Diagnostic EnrollmentBreast Diagnostic Enrollment Lesson 
Everything you need to know about the EWM Breast Diagnostic Enrollment, Follow-up and Treatment Plan

 

Cervical Diagnostic Enrollment/Follow-Up Treatment
  English
  Spanish
  Cervical Diagnostic Instructions

Cervical Diagnostic EnrollmentCervical Diagnostic Enrollment Lesson
Everything you need to know about the EWM Cervical Diagnostic Enrollment, Follow-up and Treatment Plan

Client Informed Refusal Form

English
Spanish

State Pap Plus Program Forms

State Pap Plus Program Provider Update (revised, November 2015)
State Pap Plus Program Q & A (revised, November 2015)
State Pap Plus Program Enrollment Checklist (optional) (revised, November 2015)

State Pap Plus Form: English Spanish

State Pap Plus Program Enrollment and Documentation Policy (January 2020)

State Pap Plus EnrollmentState Pap Plus Program Enrollment L​esson
Everything you need to know about enrollment eligibility and navigation of the State Pap Plus Program for clients under 40 years of age

Claim and Payment Status Forms and Policy

Timely Submission of Claims and Documentation Policy
Claims for services provided during a previous Fiscal Year (July 1- June 30) must be received by EWM/NCP with primary Explanation of Benefits and documentation by December 31st following the end of the Fiscal Year. Claims received after the filing deadline will be entered into the EWM/NCP Billing System and denied for Timely Filing. Claims denied for Timely Filing may not be billed to the client(s).

Claim Status Form
Payment Status Form

Nebraska Colon Cancer Program Data Entry Instructions for the Lab

Nebraska Colon Cancer Program Lab Data Entry Instructions (2020)
Nebraska Colon Cancer Program Endoscopy Form (fillable)
FOBT Fax Form 
New Med-It User Profile Form
Annual Update Med-It User Profile Form

Healthy Behavior Support Services

Every Woman Matters offers free or reduced cost Healthy Behavior Support Services to help clients reach their weight, fitness, and nutrition goals.  Healthy Behavior Support Services may include the following:

Health Coaching - clients can be connected to a health coach that is located in their area and a part of a Community Health Hub.  Health coaches help support clients and connect them to Healthy Behavior Support Services. More information can be found in the Health Coaching Flyer.

Check.Change.Control® - a free, on-line American Heart Association blood pressure monitoring program.  More information can be found at the American Heart Association's Check.Change.Control. website.

National Diabetes Prevention Program - 16-session program that helps people reduce their risk for type 2 diabetes and improve there overall health.  Sessions are taught by trained lifestyle coaches.  More information can be found at the Centers for Disease Control and Prevention's National Diabetes Prevention Program website.

Living Well - 6 session workshop that helps people who have on-going health conditions learn real-life skills for living a full, healthy life.  Workshops are interactive with 8-15 individuals who share experiences and provide support to each other.  More information can be found in the Living Well Flyer. 

Tobacco Cessation - Tobacco Free Nebraska has resources available to help your clients quit tobacco use.  More information can be found by going to the Tobacco Free Nebraska website.

Program Specific Webinars, Training and Resources

DHHS Website Review Recording

Screening EnrollmentScreening Enrollment Lesson
Everything you need to know about qualifying factors and enrollment in the Every Woman Matters and Nebraska Colon Cancer Screening Programs

Screening Card LessonScreening Card Lesson
What to do with the Screening Cards patients bring to their appointments


Tobacco QuitlineReferring EWM Clients to the Nebraska Tobacco Quitline​
How to refer your Every Woman Matters patients to the Nebraska Tobacco Quitline

 

Trainings and Continuing Education Resources

Hospital & Healthcare Guide 2019

Health Equity and Prevention Primer - web-based training series for public health practitioners and advocates interested in achieving health, safety and health equity through policy advocacy, community change, and multi-sector engagement.

CANCERcare.org - dedicated to providing free, professional support services including counseling, support groups, educational workshops, publications and financial assistance. 

PeerView Institute - dedicated to improving clinical competence and performance, patient outcomes and ultimately public health through the provision of continuing education (CME and professional development activities.  Credits are available FREE of charge for physicians and nurses.  Many classifications of topics are available.

American Academy of CME, Inc. - recognizes the importance of continuing education for professional development for healthcare professionals and the need to address clinical practice gaps that impact patient care.  The Academy provides certified continuing education to physicians, nurses, nurse practitioners, physician assistants, pharmacists, dieticians, social workers/case managers, transplant coordinators and other healthcare professionals.

Agency for Healthcare Research and Quality - clinical practice guidelines and resources are housed on this site.

Public Health and Primary Care Collaboration: A Practice-Based Approach 
The University of Minnesota is offering a one-hour course that challenges learners to discuss similarities and differences between public health departments and primary care clinics, identify problems as well as solutions, and design action steps to promote collaboration using a process-based perspective.

I want to be a provider

Paperwork needs to be filled out in order to participate as a provider.  A 2-page contract is also required.  Information about the Nebraska Colon Cancer Screening Program is included in the Women's and Men's Health Provider Contract Manual.

Provider Enrollment Cover letter
Provider Participation Enrollment Form
W9/ACH Form

Please call the office at (800) 532-2227 for more information.

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