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Nebraska Medicaid Program

Provider Information

ICF/MR 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: PDF Contacts Medicaid.

PDF Regulations

Chapter 1 Administration
Chapter 2 Provider Participation
Chapter 3 Payment for Medical Services
Chapter 31 Services in Intermediate Care Facilities for the Mentally Retarded (ICF/MR’s)
Chapter 36 Hospice Services

PDF Appendices (Forms, Reports and Instructions)

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
471-000-5 Instructions for Completing Form DM-5-MR-LTC, “Long Term Care Evaluation for Intermediate Care Facilities for the Mentally Retarded”
471-000-13 Instructions for Completing Form DM-27M, “ICF Utilization Review Minutes”
471-000-16 Instructions for Completing Form DM-28-MR, “Intermediate Care Facility for Mentally Retarded Utilization Review”
471-000-19 Form DM-27MR-S, “ICF/MR Annual Onsite Review Summary Report,” and Completion Instructions
471-000-28 Instructions for Completing Form ASD-100, “De-Institutionalization Referral”
471-000-41 Instructions for Completing Form FA-66, “Long Term Care Cost Report”
471-000-42 Instructions for Completing Form FA-66MR, “Intermediate Care Facilities for the Mentally Retarded Cost Report Supplement”
471-000-49 Claims Submission Table
471-000-50 Standard Electronic Transaction Instructions
471-000-68 Form IM-8, “Notice of Finding”, and Completion Instructions
471-000-79 Form EA-160, "Record of Health Cost - Share of Cost - Medicaid Program", and Completion Instructions
471-000-82 Instructions for Completing Turnaround MC-4, “Long Term Care Facility Turnaround Billing Document”
471-000-85 Explanation of Remittance Advice and Refund Requests Report
471-000-87 Example of Form MC-2, "Electronic Attachment Control Number Form"
471-000-99 Medicaid Claim Adjustment and Refund Procedures
471-000-100 Form MCP575, "Casualty Insurance Policy Information Sheet"
471-000-104 Instructions for Completing Form MC-81, “Medical Assistance Long Term Care Provider Agreement”
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)
471-000-127 Explanation of Deleted Medicaid Claims Weekly Report (MCP564-D)
471-000-128 Explanation of Medicaid Claims in Process Over 30 Days Report (MCP564-S)
471-000-203 Instructions for Completing Form MC-9NF, “Prior Authorization for Nursing Facility Care”
471-000-211 Form MC-10, “Prior Authorization Document Adjustment”, and Completion Instructions

PDF Provider Bulletins

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

Documents in PDF PDF format require the use of Adobe Acrobat Reader which can be dowloaded for free from Adobe Systems, Inc.