Physician/Laboratory 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


Chapter 1 Administration
Chapter 2 Provider Participation
Chapter 3 Payment for Medical Services
​Chapter 18​Physicians' Services
​Chapter 33​Health Checks and Treatment Services for Conditions Disclosed during Health Checks (EPSDT)


Appendices (Forms, Reports and Instructions)
​471-000-2​Form DM-5, “Physician's Confidential Report," and Completion Instructions
​471-000-10​Instructions for Completing “Nebraska Medicaid Telehealth Patient Consent" Form
​471-000-38​Form EPSDT-5, “Health Check Plan of Care," and Completion Instructions
471-000-49 Claims Submission Table
471-000-50 Standard Electronic Transaction Instructions
471-000-58 Example of Form CMS-1500, “Health Insurance Claim Form" (formerly HCFA-1500)
​471-000-62​Billing Instructions for Physician, Laboratory, and Ambulatory Surgical Center (ASC) Services
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
​471-000-84​Form MC-6, “Physician's Certification Form," and Completion Instructions
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"
​471-000-109​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
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)


​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