Personal Assistance Services 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

This handbook will be updated as regulations are updated.  

Chapter 1 Administration
Chapter 2 Provider Participation
Chapter 3 Payment for Medical Services
Chapter 15 Personal Assistance Services


Appendices (Forms, Reports and Instructions)
471-000-60​Instructions for Completion of Form HHS-5N, “N-FOCUS Health and Human Services Billing Document"
​471-000-74​Appendix 471-000-74 Instructions for Completing Form MC-39
​471-000-94​Instructions for Completing Form MC-84, “Personal Assistance Provider Check List"
​471-000-95​“Service Needs Assessment/Plan"
​471-000-106​“Provider Authorization"
​471-000-107​Instructions for Completing Form MILTC-4D. "Physician/RN Statement for Health Maintenance Activities"
​471-000-108​“Provider Authorization Update"
​471-000-112​Instructions for Completing Form IRS-2678, "Employer Appointment of Agent"
471-000-123 Explanation of Nebraska Medicaid Eligibility Documents


​​Additional Information
Electronic Visit Verification​
The Federal 21st Century Cures Act (2016) required Nebraska to implement a new electronic visit verification (EVV) system for Personal Assistance Services providers. This system launched on January 3, 2021. EVV electronically captures and verifies provider visit information. ​