Paper Claim Return Notice FAQ

Nebraska Medicaid requires the Patient's 11-digit Medicaid ID number in order to adjudicate any claim. When the Medicaid ID number is invalid or missing, the claim must be returned.

CMS 1500 Billing Instruction: (See 471-000-62 page 3 in the 471 Appendix)

Field 1A. INSURED'S I.D. NUMBER: Enter the Medicaid client's complete eleven-digit identification number (Example: 123456789-01).

UB-04 Billing Instruction: (See 471-000-83 page 6 in the 471 appendix).

Field 60. Insured's Unique Identification Required

Enter the Medicaid client's complete eleven-digit identification number (example: 123456789-01).

Nebraska Medicaid requires the 8-digit numeric date of service for each procedure/service billed. When the information is missing or invalid the claim must be returned for correction.

CMS 1500 Billing Instruction: (See 471-000-62 page 5 in the 471 appendix).

Field 24A. DATE(S) OF SERVICE: In the unshaded area, enter 8-digit numeric date of service rendered. Each procedure code/service billed requires a date. Each service must be listed on a separate line. The "from" date of service must be completed. The "to" date of service may be left blank. If billing for CONSECUTIVE days at the same care level, claims must state the beginning (under “from") and ending date (under “to").

UB-04 Billing Instruction: (See 471-000-83 page 3 in the 471 appendix).

Field 6. Statement Covers Period Required.

Nebraska Medicaid requires a valid diagnosis for the services reported on the claim form. Any claim with an invalid or missing diagnosis code must be returned for correction. Nebraska Medicaid does not accept e-codes.

CMS 1500 Billing Instruction: (See 471-000-62 page 4 in the 471 appendix)

Field 21. DIAGNOSIS OR NATURE OF ILLNESS OF INJURY: The services reported on this claim form must be related to the diagnosis entered in this field. V codes are accepted when submitting for HEALTH CHECK services and certain family planning services. Enter the appropriate International Classification of Disease, 9th Edition, Clinical Modification (ICD-10-CM) diagnosis codes. The COMPLETE diagnosis code is required. (A complete code may include the third, fourth, and fifth digits, as defined in ICD-10-CM.) Up to four diagnoses may be entered. If there is more than one diagnosis, list the primary diagnosis first.

Nebraska Medicaid requires the national two-digit place of service codes on all claims submitted on the CMS 1500 form. Claims will be returned if no information is present in this field or the information submitted is invalid.

CMS Billing Instruction: (See 471-000-62 page 5 in the 471 appendix)

Field 24B. PLACE OF SERVICE: In the unshaded area, enter the national two-digit place of service code that describes the location the service was rendered. National place of service codes are defined by the Centers for Medicare and Medicaid Services (CMS) and published on the CMS website at http://www.cms.hhs.gov.

Nebraska Medicaid requires a valid day/unit value on each claim. This value measures the specific time or quantity increments associated with the billed service charge. If this field is blank or invalid the claim must be returned to be corrected.

CMS 1500 Billing Instruction: (See 471-000-62 page 6 in the 471 appendix).

Field 24G. DAYS OR UNITS: Enter the number of times the service was provided on the date of service. If the procedure code description includes specific time or quantity increments, each increment should be billed as one unit of service.

Nebraska Medicaid requires the total of all charges found in Field 24F. If the total is incorrect or missing the claim must be returned for correction.

CMS Billing Instruction: (See 471-000-62 page 7 in the 471 appendix).

Field 28. TOTAL CHARGE: Enter the total of all charges in Field 24F. If more than one claim form is used to bill for services provided, EACH claim form must be submitted with the line items totaled. DO NOT carry charge forward to another claim form.

UB-04 Billing Instruction: (See 471-000-83 page 5 in the 471 appendix).

Field 47. Total Charges (by Revenue Code Category) Required.

Total charges must be greater than zero unless two or more operative procedures during a single session are billed. Only the first procedure requires a charge. Do not submit negative amounts.

Nebraska Medicaid requires a signature from an authorized representative. A signature stamp, computer-generated or typewritten signature will also be accepted. If no information is present in the signature field, the claim must be returned for correction.

CMS Billing Instruction: (See 471-000-62 page 8 in the 471 appendix).

Field 31. SIGNATURE OF PHYSICIAN OR SUPPLIER: The provider or authorized representative must SIGN and DATE the claim form. A signature stamp, computer-generated or typewritten signature will be accepted. The signature date must be on or after the dates of service listed on the form.

Claims submitted on the UB-04 claim form require the patient's gender to be reported. If the information provided is invalid or missing the claim must be returned for correction.

UB-04 Billing Instruction: (See 471-000-83 page 3 in the 471 Appendix).

Field 11. Patient Sex Required

Claims submitted on the UB-04 require a valid revenue code in order to be processed. Any claim containing an invalid or missing revenue code must be returned for correction.

UB-04 Billing Instruction: (See 471-000-83 page 5 in the 471 appendix).

Field 42. Revenue Code Required.

All claims submitted on the UB-04 require the patient's date of birth in order for the claim to be processed. Any claim with an invalid or missing date of birth must be returned for correction.

UB-04 Billing Instruction: (See 471-000-83 page 3 in the 471 Appendix).

Field 10. Patient Birth Date Required.

The patient is the person who received services.

All claims submitted on the UB-04 require the type of bill in order to be processed. Any claim with an invalid or missing type of bill must be returned for correction.

UB-04 Billing Instruction: (See 471-000-83 page 3 in the 471 appendix).

Field 4. Type of Bill Required.

When submitting paper claims you must include all appropriate attachments on each claim form.  We are unable to accept multiple claims with only one Explanation of Benefits attached.  You must staple a copy to each claim in order for the claim to be accepted.  In addition, each claim needs to be separately totaled.