All Medicaid providers must enroll with the program. Maximus handles provider enrollment.
To complete electronic provider enrollment or update your to existing agreement, visit Maximus's website.
Maximus Customer Service can be reached by phone and email:
Completed paper enrollment packets can be sent to the email address above or mailed to:
Maximus Nebraska Medicaid Provider Enrollment P.O. Box 81890 Lincoln, Nebraska 68501
Service coordinators or social services worker will request your enrollment as a provider if a services recipient would like you to provide services. Once contacted, you will receive a referral packet with the steps to follow in the enrollment process
February 2, 2016 Policy regarding in-home service providers who are state employees: Policy
If you are a non-emergency transportation services provider interested in enrolling, contact Maximus at (844) 374-5022.
1. Print and complete the MC-19 (Instructions are on the MC-19-I) and applicable medical assistance provider addendums per the list below by provider type. Provider enrollment instructions continue below the list of addendums.
Forms are available at http://public-dhhs.ne.gov/Forms/Default.aspx
Provider Agreement Forms
Service Provider Agreement-used by all provider types: MC-19
Service Provider Agreement Instructions: MC-19-I
Electronic Funds Transfer (EFT) (Required for new providers): MS-84
Ownership/Controlling Interest and Conviction Disclosure (Required for enrollment and to report changes. Form is fillable. Complete on line, then print and mail to DHHS): MLTC-62
Authorization for Direct Deposit or US Bank ReliaCard (HCBS/NFOCUS providers only): FA-100
W-9 Tax Identification Number and Certification form: W-9
Service Provider Agreement Addendum Forms
Service Provider Addendum - HCB/NFOCUS only: MC-190
Provider Release of Info/Felony-Misdemeanor Statement - HCB/NFOCUS only: MC-199
Non-Emergency Transportation Addendum: MC-211
Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs:
Information about federal exclusions, including databases of excluded individuals and entities, can be found on the Office of Inspector General's website.
For information on tax-related questions, see below:
Medicaid providers have the option to receive their payment via Direct Deposit or ReliaCard. Disclosures related to ReliaCard payment election are provided through the link below: