DME, Medical Supplies, Orthotics & Prosthetics Handbook

 
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Medicaid Related Assistance
Medicaid & Long-Term Care
 
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What you need to know

​​This handbook is your primary resource on the Nebraska Medicaid program, including program regulations and service coverage requirements, as well as limitations, forms, billing requirements, and payment information.

Please review this handbook before providing services and requesting payment from Nebraska Medicaid, and share the handbook with personnel who perform referrals, authorization, coding, and claims submission for your office.

Regulations

The following chapters under Regulation Title 417 Nebraska Medical Assistance  Program Services can be found on the Secretary Of State's website: 

  • Chapter 1: Administration
  • Chapter 2: Provider Participation
  • Chapter 3: Payment for Medical Services
  • Chapter 7: Durable Medical Equipment and Medical Supplies

Appendices (Forms, Reports and Instructions)
471-000-49 Claims Submission Table
471-000-50 Standard Electronic Transaction Instructions
471-000-55 Billing Instructions for Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics
471-000-58 Example of Form CMS-1500, "Health Insurance Claim Form" (formerly HCFA-1500)
471-000-70 Nebraska Medicaid Billing Instructions for Medicare Crossover Claims
471-000-79 Form EA-160, "Record of Health Cost-Share of Cost-Medicaid Program" and Completion Instructions
​471-000-80

​Nebraska Medicaid Long-Term Care UB-04 Billing Instructions for Durable Medical Equipment (DME) submitted by Nursing Facilities (NFs) NFs and Intermediate Care Facilities (ICFs)

471-000-85 Explanation of Remittance Advice and Refund Requests Report
471-000-87 Example of Form MC-2, "Electronic Attachment Control Number Form"
471-000-90 Form MC-19, "Medical Assistance Provider Agreement" and Completion Instructions
471-000-99 Medicaid Claim Adjustment and Refund Procedures
471-000-100 Form MCP575, "Casualty Insurance Policy Information Sheet"
471-000-122 Nebraska Health Connection: Listing of Plans and Vendors
471-000-123 Explanation of Nebraska Medicaid Eligibility Documents
471-000-124 Instructions for Using the Nebraska Medicaid Eligibility System (NMES)
471-000-127 Explanation of Deleted Medicaid Claims Weekly Report (MCP564-D)
471-000-128 Explanation of Medicaid Claims in Process Over 30 Days Report (MCP564-S)
​471-000-206​Form MS-77, "Request for Prior Authorization," and Completion Instructions
​471-000-207​Instructions for Completing Form MS-78, "Augmentative Communication Device Selection Report"
​471-000-208

​Form MS-79, "Wheelchairs and Wheelchair Seating System Equipment Selection Report," 

and Completion Instructions

​471-000-209

​Form MS-80, "Air Fluidized and Low Air Loss Bed Certification of Medical Necessity," and Completion Instructions