ICF/DD 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.

If you have questions or comments about this information, contact the Medicaid program specialist for this service type: Medicaid Contacts

Table of Contents
Chapter 1 Administration
Chapter 2 Provider Participation
Chapter 3 Payment for Medical Services
Chapter 31​Services in Intermediate Care Facilities for the Developmentally Disabled (ICF/DDs)
Chapter 36​Hospice Services


Appendices (Forms, Reports and Instructions)
​471-000-1​Form EA-117, “Application for Assistance, and Completion Instructions
​471-000-2​Form DM-5, “Physician's Confidential Report" and Completion Instructions
471-000-5​Instructions for Completing Form DM-5-DD-LTC, “Long Term Care Evaluation for Intermediate Care Facilities for Persons w/Developmental Disabilities"
​471-000-16​Instructions for Completing Form DM-28-MR, “Intermediate Care Facility for Persons w/Developmental Disabilities Utilization Review"
​471-000-41​Instructions for Completing Form FA-66, “Long Term Care Cost Report"
​471-000-42​Instructions for Completing Form FA-66MR, “Intermediate Care Facilities for Persons w/Developmental Disabilities Cost Report Supplement"
471-000-49 Claims Submission Table
471-000-50 Standard Electronic Transaction Instructions
​471-000-68​Form IM-8, “Notice of Finding", and Completion Instructions
471-000-79 Form EA-160, "Record of Health Cost-Share of Cost-Medicaid Program" and Completion Instructions

Nebraska Medicaid Long-Term Care UB-04 Billing Instructions for Durable Medical Equipment (DME) submitted by Nursing Facilities (NF's) 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)
471-000-203​Instructions for Completing Form MC-9NF, “Prior Authorization for Nursing Facility Care"


Provider Bulletins
​Provider Bulletin 16-10​Changes in the Intermediate Care Facilities for Individuals with Developmental Disabilities (ICF/DD) Utilization Review (UR) Process
Provider Bulletin 07-07​Clarification of Facility Obligation to Reimburse for Nurse Aide Training and Competency Evaluation Program (NATCEP) Costs