NEBRASKA MEDICAID PROGRAM

How To Enroll in the Nebraska Medicaid Program

If you are a nursing facility, contact Joette Novak at 402-471-9279 or Joette.Novak@nebraska.gov to begin the enrollment process.

If you are a personal assistance provider, contact your local DHHS office to begin the enrollment process.

Print and complete the applicable Medical Assistance Provider forms..

Provider Agreement Forms	Form
Physician/Practitioner/Supplier/Schools	MC-19
Hospital/Dialysis	MC-20

Additional Forms	Form
Electronic Funds Transfer (EFT) *Required for new providers	ACH
Ownership Disclosure *Required for new providers	MLTC-62
W-9 Tax Identification Number and Certification form (link to IRS website)	W-9

Attach additional information.

W-9 Tax Identification Number and Certification form - Required for all Providers.

Copy of license - required for hospitals and out of state providers only

Medicare/CNN CMS Certification Number, if applicable.

If you are a mental health or substance abuse provider, additional information is needed for enrollment: Mental Health & Substance Abuse Provider Enrollment

Mail or fax the completed Provider Agreement form, EFT form, Ownership Disclosure form and attachments to the address below.

Department of Health and Human Services
ATTN: Medicaid Provider Enrollment
P.O. Box 95026
Lincoln, NE 68509-5026
Fax - 402-742-2373

Keep Your Provider Agreement Current

Moving/Address Change: Fax (402-742-2373) or mail written notification. Include your old and new address and your current Nebraska Medicaid provider number in the letter.

Expanding To A New Location: Complete a new provider agreement form for the new office. Each office location must have a separate Nebraska Medicaid provider number.

New Member Joining Your Group Practice: Complete a new provider agreement form for the new practitioner. Be sure to include your current Nebraska Medicaid provider number on the form and indicate the requested effective date.

Member Leaving Your Group Practice: Fax (402-742-2373) or mail written notification. Include the name of the member, the date of departure, and your current Nebraska Medicaid provider number in the letter.

New Federal Tax ID Number (FTIN): Complete a new Provider Agreement form, EFT form, Ownership Disclosure form, and required attachments. Be sure to include your current Nebraska Medicaid provider number on the Provider Agreement form.

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