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Nebraska Medicaid Program

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Dental Provider Handbook

The links below comprise your Nebraska Medicaid Provider Handbook. This handbook is your primary resource for information about the Nebraska Medicaid Program, including program regulations, service coverage requirements and limitations, forms, billing requirements, and payment information.

Please review this handbook prior to providing services and requesting payment from Nebraska Medicaid and share it with personnel who perform referrals, authorization, coding and claims submission for your office.

If you have questions or comments about this information, contact the Medicaid Program Specialist for the type of service: Contacts Medicaid.

Regulations

Table of Contents

Chapter 1	Administration
Chapter 2	Provider Participation
Chapter 3	Payment for Medical Services
Chapter 6	Dental Services

Appendices (Forms, Reports and Instructions)

471-000-10	Instructions for Completing "Nebraska Medicaid Telehealth Patient Consent" Form
471-000-49	Claims Submission Table
471-000-50	Standard Electronic Transaction Instructions
471-000-72	Prior Authorization Dollar Limits for Dental Services
471-000-79	Form EA-160, "Record of Health Cost - Share of Cost - Medicaid Program", and Completion Instructions
471-000-85	Explanation of Remittance Advice and Refund Requests Report
471-000-87	Example of Form MC-2, "Electronic Attachment Control Number Form"
471-000-88	Instructions for Completing the 2006, 2002, 1999 and 1994 ADA Dental Claim Form
471-000-90	Form MC-19, "Medical Assistance Provider Agreement" and Completion Instructions
471-000-99	Medicaid Claim Adjustment and Refund Procedures
471-000-100	Form MCP575, "Casualty Insurance Policy Information Sheet"
471-000-121	Explanation of Form PDS-38B, "Nebraska Health Connection ID Document"
471-000-122	Nebraska Health Connection: 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)
471-000-126	Procedure Codes Subject to Copayment Requirements
471-000-127	Explanation of Deleted Medicaid Claims Weekly Report (MCP564-D)
471-000-128	Explanation of Medicaid Claims in Process Over 30 Days Report (MCP564-S)
471-000-201	Instructions for Completing Form MC-9D, "Dental Treatment and Prior Authorization"
471-000-406	Orthodontic Diagnostic Score Sheet and Other Information
471-000-506	Nebraska Medicaid Practitioner Fee Schedule for Dental Services

Provider Bulletins

Number	Subject	Date
08-24	Fee Schedule Update	06/26/08
08-18	$1000 Annual Dental Benefit Limit for Adults	06/30/08
08-12	DHHS Website Email Notification Feature, Online Provider Handbooks and Provider Bulletins, Electronic Claims, Funds Transfer and Other Options	05/12/08
08-06	Tamper-Resistant Presciption Pads for the Nebraska Medicaid Pharmacy Program (Revised)	03/14/08
08-04	Pregnancy - Related Services for the Ineligible Mother of an Eligible Unborn Child	02/11/08
07-20	Tamper-Resistant Prescription Pads for the Nebraska Medicaid (Rescind effective 03/14/08)	09/05/07
07-10	New Medicaid Claim Reports – New Process for Reporting Deleted Medicaid Claims	05/09/07
07-02	Medicaid Dental Fee Schedule - CDT - 2007/2008	01/16/07

Go to Rules and Regulations and Provider Bulletins for all Medicaid regulations, appendices and bulletins.

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