Provider Screening and Enrollment

Medicaid Related Assistance
Medicaid & Long-Term Care

What would you like to do?

What you need to know

​​​​​How to Enroll in the Nebraska Medicaid Program

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.

Provider Enrollment Forms — Paper

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

Provider Agreement Forms​

Service Provider Agreement-used by all provider types: MC-19

Service Provider Agreement Instructions: MC-19-I

Additional Forms

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​


2. Attach additional information.
  • MS-84 – Required for all providers
  • MLTC-62 – Required for all providers
  • W-9 Tax Identification Number and Certification form - Required for all providers
  • Copy of license – Required for all licensed provider types
  • Medicare/CNN CMS Certification Number, if applicable.

Additional Information

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:

Medicaid Customer Service 
Department of Health & Human Services
Phone Number
(402) 471-9128
Toll Free Number
(877) 255-3092