Provider enrollment for Home and Community-based Service Providers

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. Providers may not have to fill out all of the forms listed below. Questions regarding which forms should be submitted based on provider type can be directed to Maximus.
1. ​​Provider Agreement Forms
1. ​MC-19: Service Provider Agreement
   
2. ​MC-19-I: Service Provider Agreement Instructions
   
2. Service Provider Agreement Addendum Forms
1. MC-190​: Service Provider Addendum  
2. MC-199: ​Provider Release of Info/Felony-Misdemeanor Statement 
   
3. ​MC-211: Non-Emergency Transportation Addendum
   
2. Attach additional information.
   
1. MS-84: Required for all providers
2. MLTC-62: Required for all providers (Required for enrollment and to report changes. Form is fillable. Complete online, then print and mail to DHHS)
3. W-4: Tax Identification Number and Certification form - Required for all providers
4. Copy of license or certification – Required for all provider types​
   
5. FA-100: Authorization for Direct Deposit or US Bank ReliaCard
   

To add NEMT services to an existing Medicaid agreement, or enroll as a new provider, please contact the Public Service Commission in the following ways: 

• Phone: (402) 471-3101
  
• Toll-Free: 1-800-526-0017
  
• TDD: 771
  
• Email: PSC.General@Nebraska.gov 
  
• Mail: 1200 N Street, Suite 300 Lincoln, Nebraska 68508
  

The commission will review the provider's application and let Provider Relations k​now if the provider can provide NEMT services for Medicaid clients within a designated area.

1. ​​Resource Developer (RD worker) makes a provider referral to Maximus.
2. The provider creates an account with Maximus using their referral number and submits the referral when completed.
   
3. Maximus helps with the enrollment process, answers questions, and reviews background checks.
4. Once Maximus has gathered and reviewed the background checks, the provider information is sent to the Provider Relations team at Nebraska Medicaid.
   
5. The Provider Relations Team reviews the information. If the provider passes screening, they will receive the following materials: 
   
1. A Fingerprint Criminal Background Check (FCBC) Request Packet for each owner in the provider's agency.
1. In this process, an owner is defined as someone who owns a 5%, or more, stake in the company.
2. ​A letter requesting the provider to supply their Policies and Procedures.
   
6. The Provider must follow all requirements and submit the necessary documents.
   
7. Once the Provider Relations Team receives the necessary paperwork, the provider's information is reviewed and the team determines if the provider is eligible to provide Medicaid services in Nebraska.
   
8. If the provider is approved, the RD worker and provider receive a welcome letter from Maximus.
   
9. The provider must contact the RD worker to complete the enrollment process.​
   

More information on the enrollment process can be found here​.

In February 2016, policies were put in place regarding the ability of state employees to provide in-home services in Nebraska. Before state employees begin the application process to become a Nebraska Medicaid provider, they should consult with their supervisor and/or Human Resources.​

State employees may not enroll as providers except under the following circumstances: 

1. The Department of Health and Human Services (DHHS) CEO, or their designee, determine that the employee would not be a dual or joint employee; or,
   
2. The CEO, or their designee, granted a consumer-specific exception.