Provider Information & Forms

46
7
Lifespan Health
Public Health
https://public.govdelivery.com/accounts/NESTATE/subscriber/new?topic_id=NEDHHS_150
Share facebook icon x icon copy action icon
Yes
No

What would you like to do?

What you need to know

​​​Thank you for providing health care services for Women's and Men's Health Programs, which includes Every Woman Matters and the Nebraska Colon Cancer Screening Program.  Screening and early cancer detection is an important step in helping Nebraskans live longer, healthier lives.

Already a provider and want some in person or online training? 
If you are interested in finding out more about program training for your clinic (to review processes, procedures, and policies), please contact us!​  

​Are you considering becoming an enrolled health care provider? 
Click on the "I Want to be a Provider" tab below to find more information and specific enrollment forms. 

If you have specific questions regarding Every Woman Matters or the Nebraska Colon Cancer Screening Program, please call 1-800-532-2227.​​

​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​

Contracted Pro​vider (doctors and clinic) Listing

Contracted Provider Listing (visual map where you select the type of service:
Well-Woman Visit, Mammography, or Colonoscopy) and search for providers near you.​


Provider Participation Manual, Fee Schedules and Income Guidelines

Women's and Men's Health Provider Participation Manual (EFFECTIVE: October 1, 2024)​

Women's and Men's Health Fee Schedule​ (2025-2026 - EFFECTIVE:  July 1, 2025) 
Women's and Men's Health Fee Schedule​ (2024-2025 - EFFECTIVE:  July 1, 2024)

Income Eligibility Guidelines (EFFECTIVE:  July 1, 2025)​

Cholesterol Recommendations
Hypertension Recommendations​

Medicaid Expansion Information

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​

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
Mammography Order Form
Tobacco Free Nebraska Quitline Fax Referral​​ 

Diagnostic Enrollment/Follow-Up and Treatment Forms

Diagnostic Presumptive Eligibility Checklist
Diagnostic Reference Quick Guide​

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

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

WANT TO LEARN MORE?:

Breast Diagnostic Enrollment Lesson​ - Everything you need to know about breast diagnostic enrollment in EWM
Cervical Diagnostic Enrollment Lesson​ - Everything you need to know about cervical diagnostic enrollment in EWM​​​​

Presumptive Enrollment

All contracted Women's and Men's Health (WMHP) provider sites can offer PRESUMPTIVE ENROLLMENT for preventive screening services. If a patient comes in for services and they are eligible for Every Woman Matters (EWM) or the Nebraska Colon Cancer Screening Program (NCP), you, as a clinic, can enroll them that day and provide services the same day.  Clinics will be responsible for determining client eligibility.

Reduce barriers for your patients!  Currently, if a patient is eligible, they fill out the Healthy Lifestyle Questionnaire (HLQ), program staff review it, and a Screening Card is mailed to the client within 2-3 weeks.  Get your patients screened sooner! 

Clinics MUST be trained and approved as a Presumptive Enrollment Provider

STEPS TO PROVIDE PRESUMPTIVE ENROLLMENT FOR YOUR CLIENTS:  

  • STEP 1: COMPLETE a Training
    Contact us for an in-person or virtual training with your clinic team.

OR

AND

​Provider Notice Regarding Presumptive Enrollment

Presumptive Enrollment Training Questions/Answers (COMING SOON)

Presumptive Enrollment-Healthy Lifestyle Questionnaire  (English)
Presumptive Enrollment-Healthy Lifestyle Questionnaire (Spanish)
Quitline Fax Referral​

WANT TO LEARN MORE? 
Presumptive Enrollment Lesson - Everything you need to know about enrolling a client and providing services to the client on the same day of enrollment. ​

​STI/STD Assistance (formerly the State Pap Plus Program)

Provider Notice Regarding STI/STD Assistance Form

STI/STD Eligibility Checklist​
STI/STD Quick Reference Guide​
STI/STD Policy:  ​Utilizing Funds Under LB321 2007, Section 107

STI/STD Assistance Form (English)
STI/STD Assistance Form (Spanish)​

​WANT TO LEARN MORE?:
STI/STD Assistance Lesson​ - Everything you need to know about enrolling a client for STI/STD Assistance​

Client Informed Refusal Form

English
Spanish

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

Screening Colonoscopy Post Positive Non-Invasive Stool Test Enrollment (English)
Screening Colonoscopy Post Positive Non-Invasive Stool Test Enrollment​ (Spanish)

Nebraska Colon Cancer Program Lab Data Entry Instructions
Nebraska Colon Cancer Program Endoscopy Form​
FIT Fax Form​ 
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 - Connect with a health coach that will help support your goals for a healthy lifestyle.  Explore
additional resources and supports available in your community and virtually!  Health coaching can be done virtually or by phone.  3 sessions scheduled to match your needs and availability.  More information can be found in the Health Coaching Flyer.

Health Coaches for Hypertension Program - Program for individuals with high blood pressure or at risk for developing high blood pressure.  Topics include blood pressure tracking, nutrition, physical activity, stress management, tobacco cessation, and medication management. Virtual or may be available in your community in-person.  

National Diabetes Prevention Program - In person or virtual program for people who have prediabetes or are at risk of Type 2 diabetes, but who do not already have diabetes.  16 weekly sessions and monthly follow-up sessions. 
Topics include healthy eating, physical activity, stress management and goal setting.  

Living Well - For people with diverse medical diagnoses such as diabetes, arthritis, and hypertension develop skills and coping strategies to manage their symptoms.  Virtual or in-person workshops in some communities. 

Walk & Talk Toolkit - Small group program may be available in your community!  10 weeks of “walk and talk" sessions covering topics to help you live a healthier life.   

Tobacco Cessation - Ready to quit tobacco?  1-800-QUIT-NOW (784-8669).  Free Quitline services are available
24/7 in over 200 languages.  Web-based coaching is also available.  Encouragements throughout your quit journey.​ More information can be found by going to the Tobacco Free Nebraska website.

Program Specific Webinars, Training and Resources

Screening 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 Lesson​ - What to do with the Screening Cards patients bring to their appointments

Breast Diagnostic Enrollment Lesson - Everything you need to know about breast diagnostic enrollment in EWM

Cervical Diagnostic Enrollment Lesson​ - Everything you need to know about cervical diagnostic enrollment in EWM​

Colon Cancer Program Lesson​​ - Everything you need to know about the Nebraska Colon Cancer Screening Program

Other Important Forms​​ - How to use other forms and resources from EWM

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


Women's & Men's Health Quick Reads Newsletter - Provider Updates, Highlights & Prevention Insights:
Issue 4: July 2025
Issue 3: April 2025
Issue 2: February 2025
Issue 1: October 2024  ​


Trainings and Continuing Education Resources
The Health Resources and Services Administration (HRSA) and the Federal Cervical Cancer Collaborative (FCCC) released a new resource, Improving Patient Engagement in Cervical Cancer Prevention: Communication Toolkit for Health Centers and Safety-net Settings of Care​.  The Patient Engagement Toolkit supports to increase patient and community engagement in cervical cancer prevention, screening, and management.  Materials include social media posts, posters, a cervical screening follow-up card and more.  Toolkit/Materials are available in English and Spanish.

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.​

Nebraska Tobacco Quitline Adds Continuing Education Opportunity for Healthcare Providers:  Accredited courses are now available online, through the Nebraska Tobacco Quitline, for providers looking to receive CME, CNE, or CPE credits.  To access tools, resources, and education modules, plus the web and fax referrals for providers ready to help patients quit, go to: QuitNow.ne.gov/providers  

I want to be a provider

In order to participate as a provider, a 6-page Provider Participation Enrollment Form is required.  Information about the Women's and Men's Health programs are included in the Women's and Men's Health Provider Participation Manual. Please call the office at (800) 532-2227 for more information.

Provider Enrollment Coverle​tter​
Provider Participation Enrollment Form
W9/ACH Form

Women's and Men's Health Provider Participation Manual​ (EFFECTIVE: October 1, 2024)

Women's and Men's Health Fee Schedule​ (2025-2026 - EFFECTIVE:  July 1, 2025)

Provider One Pager - How do you know if a client is eligible?​ 

I want to schedule a training for our clinic!

Training for clinics is offered via zoom or in person, depending upon location.  If you are interested in finding out more about program training for your clinic (to review processes, procedures, and policies), please contact us!