| Number | Name |
| 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 |
| 471-000-3 | Form DM-5H, "Physician's Report on Hearing Loss" and Completion Instructions |
| 471-000-4 | Form MLTC-78 Instructions for Completing Form MLTC-78 "Prior Authorization for Specialized Add-On Services" |
| 471-000-5 | Instructions for Completing Form DM-5-DD-LTC, "Long Term Care Evaluation for Intermediate Care Facilities for the Individuals with Developmental Disabilities" |
471-000-6
| Billing Instructions for Specialized Add-On Services Utilizing CMS-1500 Claim Form
|
471-000-7 through 8
| (Reserved)
|
| 471-000-9 | Form DM-12, "Social Study," and Completion Instructions |
| 471-000-10 | Instructions for Completing "Nebraska Medicaid Telehealth Patient Consent" Form |
| 471-000-11 | Nursing Facility Administrator Compensation Maximums |
| 471-000-12 through 15 | (Reserved) |
| 471-000-16 | Instructions for Completing Form DM-28-MR, "Intermediate Care Facility for Mentally Retarded Utilization Review" |
471-000-17 through 38
| (Reserved) |
| 471-000-39 | Dental Periodicity Schedule for Children |
| 471-000-40 | (Reserved)
|
| 471-000-41 | Form FA-66, “Long-Term Care Cost Report" and Instructions |
471-000-42
| Form FA-66 ICF/DD, “Long-Term Care Cost Report Supplement" and Instructions |
| 471-000-43 through 44 | (Reserved) |
| 471-000-45 | Instructions for Completing Form MC-75-7, "MDS Section S" |
| 471-000-46 through 48 | (Reserved) |
| 471-000-49 | Claims Submission Table |
471-000-50
| Standard Electronic Transaction Instructions |
| 471-000-51 | Form CMS-1450 (UB-04), "Health Insurance Claim Form", (Formerly HCFA-1450) |
| 471-000-52 | Billing Instructions for Ambulatory Surgical Center (ASC) Services |
| 471-000-53 | Billing Instructions for Ambulance Services |
| 471-000-54 | Billing Instructions for Chiropractic Services |
| 471-000-55 | Billing Instructions for Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics |
| 471-000-56 | Billing Instructions for Hearing Aid Services |
| 471-000-57 | Billing Instructions for Home Health Agency Services |
| 471-000-58 | Form CMS-1500, "Health Insurance Claim Form" |
| 471-000-59 | Nebraska Medicaid Billing Instructions for Completing Form MC-82N, "Private Duty Nurse Claim Form" for Private Duty Nursing Services |
| 471-000-60 | Instructions for Completing Form MC-82, "Personal Care Aide Claim Form" |
| 471-000-61 | Billing Instructions for Physical Therapy, Speech Pathology and Audiology Services, and Occupational Therapy |
| 471-000-62 | Billing Instructions for Physician, Laboratory, and Ambulatory Surgical Center (ASC) Services |
| 471-000-63 | Billing Instructions for Podiatry Services |
| 471-000-64 | Billing Instructions for Mental Health and Substance Abuse Services |
| 471-000-65 | Billing Instructions for Visual Care Services |
| 471-000-66 | Example of Form HCFA-1539, "Medicare/Medicaid Certification and Transmittal" |
| 471-000-67 | Form MS-81, "Certification and Plan of Care for Private-Duty Nursing", and Completion Instructions |
| 471-000-68 | Form IM-8, "Notice of Finding", and Completion Instructions |
| 471-000-69 | Instructions for Completing Form MS-82, "Adult Day Care Assessment/Authorization" |
| 471-000-70 | Billing Instructions for Medicare Crossover Claims |
| 471-000-71 | Nebraska Medicaid Long-Term Care UB-04 Billing Instructions for Nursing Facility, ICF/MR. Assisted Living - Waiver, Hospital Swing Bed and Hospice in Nursing Facility or ICF/MR (ICF/ID) Providers |
4710000-72
| (Reserved)
|
| 471-000-73 | Form MS-6, "Ambulatory Room and Board Agreement", and Completion Instructions |
471-000-74
| Instructions for Completing Form MC-39, "Personal Assistance Services Provider Time Sheet" |
471-000-75
| Nebraska Medicaid Billing Instructions for Completing Form MC-82-AD, "Adult Day Care nursing/Aide Services Claim Form" for Private Duty Nursing or Personal Assistance Services in Adult Day Care Centers |
| 471-000-76 | Billing Instructions for Federally Qualified Health Center Services |
| 471-000-77 | Billing Instructions for Rural Health Clinic Services |
| 471-000-78 | Nebraska Medicaid Form Locator Requirements for Form CMS-1450 (UB-04) |
| 471-000-79 | Form EA-160, "Record of Health Cost - Share of Cost - Medicaid Program", and Completion Instructions |
| 471-000-80 | Nebraska Medicaid Long-Term Care UB-04 Billing Instructions for Durable Medical Equipment (DME) submitted by Nursing Facilities (NF's) and Intermediate Care Facilities (ICF's) |
| 471-000-81 | Nebraska Medicaid Billing Instructions for Hospice Services |
| 471-000-82 | (Reserved) |
| 471-000-83 | Billing Instructions for Hospital Services |
| 471-000-84 | Form MC-6, "Physician's Certification Form", and Completion Instructions |
| 471-000-85 | Explanation of Remittance Advice and Refund Requests Report |
| 471-000-86 | Example of Form MC-38, "Notice of Lock-In Finding" |
| 471-000-87 | Example of Form MC-2, "Electronic Attachment Control Number Form" |
| 471-000-88 | Nebraska Medicaid Dental Program Completion Instructions for the 2012 ADA Dental Claim Form |
| 471-000-89 | Form MC-14, "Confidential Report", and Completion Instructions |
| 471-000-90 | Form MC-19, "Medical Assistance Provider Agreement", and Completion Instructions |
| 471-000-91 | Form MC-20, "Medicaid Hospital Provider Agreement", and Completion Instructions |
| 471-000-92 | Instructions for Completing Form MC-37, "Home Care Time Sheet" |
| 471-000-93 | Form MC-66 "Client Choice of Restricted Services (Lock-In) Provider Agreement", and Completion Instructions |
| 471-000-94 | Instructions for Completing Form MC-84, "Personal Care Aide Provider Check List" |
| 471-000-95 | Instructions for Completing Form MC-73, "Personal Care Services - Care Plan" |
| 471-000-96 | (Reserved) |
| 471-000-97 | Instructions for Completing Form HHS-100 "Private Duty" Nursing Notes |
| 471-000-98 | Nebraska Ownership/Controlling Interest and Conviction Disclosure" and Completion Instructions |
| 471-000-99 | Form MC-11D, "Return of Warrant", and Medicaid Claim Adjustments and Refund Procedures |
| 471-000-100 | Form MCP575, "Casualty Insurance Policy Information Sheet" |
| 471-000-101 | Explanation of Form MC-85, "Supplemental Explanation of Medicaid Benefits" |
| 471-000-102 | (Reserved) |
| 471-000-103 | Form HHS-6, "Notice of Action," and Completion Instructions |
| 471-000-104 through 105 | (Reserved) |
| 471-000-106 | Form MILTC-4B, "Provider Authorization Notice," and Completion Instructions |
| 471-000-107 | Form MILTC-4D, "Physician/RN Statement for Health Maintenance Activities," and Completion Instructions |
| 471-000-108 | Form HHS-4C, "Provider Notice" and Completion Instructions |
| 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 |
| 471-000-111 | Form MS-44, "Hospice Prior Authorization Request" and Completion Instructions - (See 471-000-11 for Nursing Facility Administrator Compensation Maximums) |
| 471-000-112 | IRS Form 2678, "Employer Appointment of Agent," and Completion Instructions |
| 471-000-113 through 121 | (Reserved) |
| 471-000-122 | Heritage Health Managed Care: 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) |
| 471-000-125 | (Reserved) |
| 471-000-126 | Procedure Codes Subject to Copayment Requirements |
| 471-000-127 | Instructions for Explanation of Deleted Medicaid Claims Weekly Report (MCP564-D) |
| 471-000-128 | Instructions for Explanations of Medicaid Claims in Process Over 30 Days Report (MCP564-S) |
| 471-000-129 | Instructions for Explanation of Deleted Medicaid Claims and Medicaid Claims in Process Over 30 Days Report (MCP564-DS) |
| 471-000-130 through 201 | (Reserved) |
| 471-000-202 | Income Levels for Medical Assistance for Presumptive Eligibility for Pregnant Women |
| 471-000-203 | Instructions for Completing Form MC-9NF, "Authorization for Facility Care" |
| 471-000-204 | (Reserved) |
| 471-000-205 | Form MC-9HA, "Prior Authorization Document for Hearing Aids", and Completion Instructions |
| 471-000-206 | Form MS-77, "Request for Prior Authorization," and Completion Instructions |
| 471-000-207 | Instructions for Completing Form MS-78, "Augmentative Communication Device Selection Report" |
| 471-000-208 | Form MS-79, "Wheelchairs and Wheelchair Seating System Equipment Selection Report," and Completion Instructions |
| 471-000-209 | Form MS-80, "Air Fluidized and Low Air Loss Bed Certification of Medical Necessity," and Completion Instructions |
| 471-000-210 through 219 | (Reserved) |
| 471-000-220 | Instructions for Completing Form DSS-14AD, "Functional Criteria" |
| 471-000-221 through 229 | (Reserved) |
| 471-000-230 | Instructions for Completing Form MC-OBRA-8, "Authorization for Release of Information" |
| 471-000-231 through 302 | (Reserved) |
| | |
| 471-000-303 | Form MS-91, "Presumptive Application for Pregnant Women" |
| 471-000-304 through 405 | (Reserved) |
| 471-000-406 | Orthodontic Diagnostic Score Sheet and Other Information |
| 471-000-407 through 408 | (Reserved) |
| 471-000-409 | Ambulatory Surgical Center Rates |
| 471-000-410 | Free Standing Birth Centers |
| 471-000-411 through 502 | (Reserved) |
471-000-503
| Nebraska Medicaid Fee Schedule for Non-Emergency Transportation (NET) Services |
| 471-000-504 | Nebraska Medicaid Practitioner Fee Schedule for Ambulance Services |
| 471-000-505 | Nebraska Medicaid Practitioner Fee Schedule for Chiropractic Services |
| 471-000-506 | Nebraska Medicaid Practitioner Fee Schedule for Dental Services |
| 471-000-507 | Nebraska Medicaid Practitioner Fee Schedule for Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics |
| 471-000-508 | Nebraska Medicaid Practitioner Fee Schedule for Hearing Aid Services |
| 471-000-509 | Nebraska Medicaid Home Health Agency Fee Schedule |
| 471-000-510 through 512 | (Reserved) |
| 471-000-513 | Nebraska Medicaid RN/LPN Fee Schedule |
| 471-000-514 | (Reserved) |
| 471-000-515 | Nebraska Medicaid Personal Care Aide Fee Schedule |
| 471-000-516 | (Reserved) |
| 471-000-517 | Nebraska Medicaid Practitioner Fee Schedule for Physical Therapy and Occupational Therapy |
| 471-000-518 | Nebraska Medicaid Practitioner Fee Schedule for Physician Services |
| 471-000-519 | Nebraska Medicaid Practitioner Fee Schedule for Podiatry Services |
| 471-000-520 | Clinical Lab Fee Schedule |
| 471-000-521 | Anesthesia Fee Schedule |
471-000-522
| (Reserved)
|
471-000-523
| Nebraska Medicaid Practitioner Fee Schedule for Speech Pathology and Audiology Services
|
| 471-000-524 | Nebraska Medicaid Practitioner Fee Schedule for Visual Care Services |
| 471-000-525 through 531 | (Reserved) |
| 471-000-532 | Nebraska Medicaid Practitioner Fee Schedule for Mental Health and Substance Abuse Services |
471-000-533
| (Reserved)
|
| 471-000-534 through 535 | (Reserved) |
| 471-000-536 | Nebraska Medicaid Hospice Fee Schedule |
| 471-000-537 through 539 | (Reserved) |
| 471-000-540 | Nebraska Medicaid Practitioner Fee Schedule for Injectables |
| 471-000-541 | Information on Site-of-Services-Differential |