Nebraska Medicaid Program

Provider Information

Provider Enrollment

How To Enroll in the Nebraska Medicaid Program

If you are a nursing facility, contact Melissa Haecker at 402-471-9279 or melissa.haecker@dhhs.ne.gov to begin the enrollment process.

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

1. Print the applicable Medical Assistance Provider Agreement.

2. Complete the form according to the instructions provided.

3. Attach additional information.

• W-9 Tax Identification Number and Certification form.
• 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

4. Enroll for electronic funds transfer to have your Medicaid payments deposited directly in your bank.  This is required.

5. Mail or fax the completed Provider Agreement form, attachments and EFT enrollment form 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 (402-724-2373) 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. Be sure to include your current Nebraska Medicaid provider number on the form.

All forms available on this page are in PDF format and require the use of Adobe Acrobat Reader which can be downloaded for free from Adobe Acrobat Systems, Inc.