Hospital Provider Handbook

Medicaid Related Assistance
Medicaid & Long-Term Care

What would you like to do?

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.


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 10: Hospital Services
  • Chapter 14: Occupational Therapy Services
  • Chapter 17: Physical Therapy Services
  • Chapter 20: Psychiatric Services for Individuals Age 21 and Older
  • Chapter 21: Rehabilitation Care in Hospitals
  • Chapter 22: Respiratory Therapy Services
  • Chapter 23: Speech Pathology and Audiology Services
  • Chapter 32: Mental Health and Substance Abuse Treatment Services for Children and Adolescents​

Appendices (Forms, Reports and Instructions)
​471-000-10​Instructions for Completing “Nebraska Medicaid Telehealth Patient Consent" Form
471-000-49 Claims Submission Table
471-000-50 Standard Electronic Transaction Instructions
​471-000-51​Form CMS-1450 (UB-92), “Health Insurance Claim Form" (Formerly HCFA-1450)
471-000-70 Nebraska Medicaid Billing Instructions for Medicare Crossover Claims
​471-000-73​Form MS-6, “Ambulatory Room and Board Agreement," and Completion Instructions
​471-000-78​Nebraska Medicaid Form Locator Requirements for Form CMS-1450 (UB-92)
471-000-79 Form EA-160, "Record of Health Cost-Share of Cost-Medicaid Program," and Completion Instructions
​471-000-83​Billing Instructions for Hospital Services
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
​471-000-91​Form MC-20, “Medicaid Hospital Provider Agreement," and Completion Instructions

​Form MC-83, “Mental Health/Substance Abuse Treatment Planning Document for Outpatient Services," and Completion Instructions

471-000-99 Medicaid Claim Adjustment and Refund Procedures
471-000-100 Form MCP575, "Casualty Insurance Policy Information Sheet"
​471-000-109​Form MMS-100, “Sterilization Consent Form," and Completion Instructions
​471-000-110​Form MMS-101, “Informed Consent for Hysterectomies," and Completion Instructions
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)
​471-000-126​Procedure Codes Subject to Copayment Requirements

​Explanation of Deleted Medicaid Claims and Medicaid Claims In Process over 30 Days Report (MCP564-DS)

471-000-207 Instructions for Completing Form MS-78, "Augmentative Communication Device Selection Report"

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


Provider Bulletins
​Provider Bulletin 10-60​A. Coverage of Zyprexa Relprevv
B. Revised Risperdal Consta Authorization Requirements
C. End Prior Authorization of Certain Psychiatric Injectable Medications