| 471-000-2 |
Form DM-5, “Physician’s Confidential Report” and Completion
Instructions |
| 471-000-10 |
Instructions for Completing “Nebraska Medicaid Telehealth Patient
Consent” Form |
| 471-000-38 |
Form EPSDT-5, “Health Check Plan of Care”, and Completion
Instructions |
| 471-000-49 |
Claims Submission Table |
| 471-000-50 |
Standard Electronic Transaction Instructions |
| 471-000-58 |
Example of Form CMS-1500, “Health Insurance Claim Form”
(formerly HCFA-1500) |
| 471-000-62 |
Billing Instructions for Physician, Laboratory, and Ambulatory Surgical
Center (ASC) Services |
| 471-000-66 |
Example of Form HCFA-1539, “Medicare/Medicaid Certification and
Transmittal” |
| 471-000-70 |
Nebraska Medicaid Billing Instructions for Medicare Crossover Claims |
| 471-000-79 |
Form EA-160, “Record of Health Cost-Share of Cost-Medicaid
Program” and Completion Instructions |
| 471-000-84 |
Form MC-6, “Physician’s Certification Form”, and Completion
Instructions |
| 471-000-85 |
Explanation of Remittance Advice and Refund Requests Report |
| 471-000-87 |
Example of Form MC-2, “Electronic Attachment Control Number
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” |
| 471-000-109 |
Form MMS-100, “Serilization Consent Form”, and Completion
Instructions |
| 471-000-110 |
Form MMS-101, “Informed Consent for Hysterectomies”, and
Completion Instructions |
| 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) |
| 471-000-518 |
Nebraska Medicaid Practitioner Fee Schedule for Physician Services |
| 471-000-533 |
Nebraska Medicaid Practitioner Fee Schedule for HEALTH CHECK Services |
| 471-000-540 |
Nebraska Medicaid Practitioner Fee Schedule for Injectables |
