Title 471 -- Nebraska Medical Assistance Program Services
Appendix Forms
All files are in 
PDF format.
| Form Number | Form Name |
| 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 |
| 471-000-3 | Form DM-5H, "Physician's Report on Hearing Loss" and Completion Instructions |
| 471-000-4 | (Reserved) |
| 471-000-5 | Instructions for Completing Form DM-5-MR-LTC, "Long Term Care Evaluation for Intermediate Care Facilities for the Mentally Retarded" |
| 471-000-6 | Instructions for Completing Form DM-5R, "Disability Report" |
| 471-000-7 | Example of Form DM-8, "IPR-Institutions for Mental Disease Ages 21 and Under" |
| 471-000-8 | Example of Form DM-9, "IPR-Institutions for Mental Disease Ages 65 and Older" |
| 471-000-9 | Form DM-12, "Social Study," and Completion Instructions |
| 471-000-10 | Instructions for Completing "Nebraska Medicaid Telehealth Patient Consent" Form |
| 471-000-11 | (Reserved) |
| 471-000-12 | (Reserved) |
| 471-000-13 | Instructions for Completing Form DM-27M, "ICF Utilization Review Minutes" |
| 471-000-14 and 15 | (Reserved) |
| 471-000-16 | Instructions for Completing Form DM-28-MR, "Intermediate Care Facility for Mentally Retarded Utilization Review" |
| 471-000-17 and 18 | (Reserved) |
| 471-000-19 | Form DM-27MR-S, "ICF/MR Annual Onsite Review Summary Report," and Completion Instructions |
| 471-000-20 | (Reserved) |
| 471-000-21 | Form DSS-4, "Case Information Summary" |
| 471-000-22 through 27 |
(Reserved) |
| 471-000-28 | Instructions for Completing Form ASD-100, "De-Institutionalization Referral" |
| 471-000-29 through 37 |
(Reserved) |
| 471-000-38 | Form EPSDT-5, "Health Check Plan of Care", and Completion Instructions |
| 471-000-39 | (Reserved) |
| 471-000-40 | Form FA-20, "Cost Report of Psychiatric and Chemical Dependency Facilities for Medicaid Reimbursement", and Completion Instructions |
| 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" |
| 471-000-43 | Instructions for Completing Form MC-75, "MDS 2.0" |
| 471-000-44 | Instructions for Completing Form MC-75Q, "MDS 2.0 Quarterly Review" |
| 471-000-45 | Instructions for Completing Form MC-75-7, "MDS 2.0 Section S" |
| 471-000-46 | Instructions for Completing Form MC-75R, "MDS 2.0 Re-entry Tracking Form" |
| 471-000-47 | Instructions for Completing Form MC-75D, "MDS 2.0 Discharge Tracking Form" |
| 471-000-48 | Instructions for Completing Form MC-75PS, "MDS 2.0 Resident Assessment Protocol Summary Form" |
| 471-000-49 | Claims Submission Table |
| 471-000-50 | Standard Electronic Transaction Instructions |
| 471-000-51 | Form CMS-1450 (UB-04), "Health Insurance Claim Form", (Formerly HCFA-1450) |
| 471-000-52 | Billing Instructions for Ambulatory Surgical Center (ASC) Services |
| 471-000-53 | Billing Instructions for Ambulance Services |
| 471-000-54 | Billing Instructions for Chiropractic Services |
| 471-000-55 | Billing Instructions for Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics |
| 471-000-56 | Billing Instructions for Hearing Aid Services |
| 471-000-57 | Billing Instructions for Home Health Agency Services |
| 471-000-58 | Form CMS-1500, "Health Insurance Claim Form" (formerly HCFA-1500) |
| 471-000-59 | Form MC-82N, "Private Duty Nurse Claim Form", and Completion Instructions |
| 471-000-60 | Instructions for Completing Form MC-82, "Personal Care Aide Claim Form" |
| 471-000-61 | Billing Instructions for Physical Therapy, Speech Pathology and Audiology Services, and Occupational Therapy |
| 471-000-62 | Billing Instructions for Physician, Laboratory, and Ambulatory Surgical Center (ASC) Services |
| 471-000-63 | Billing Instructions for Podiatry Services |
| 471-000-64 | Billing Instructions for Mental Health and Substance Abuse Services |
| 471-000-65 | Billing Instructions for Visual Care Services |
| 471-000-66 | Example of Form HCFA-1539, "Medicare/Medicaid Certification and Transmittal" |
| 471-000-67 | Form MS-81, "Certification and Plan of Care for Private-Duty Nursing", and Completion Instructions |
| 471-000-68 | Form IM-8, "Notice of Finding", and Completion Instructions |
| 471-000-69 | Instructions for Completing Form MS-82, "Adult Day Care Assessment/Authorization" |
| 471-000-70 | Billing Instructions for Medicare Crossover Claims |
| 471-000-71 | Form MS-65, "Medicaid Medical Transportation Services Authorization and Claim Form", and Completion Instructions |
| 471-000-72 | Prior Authorization Dollar Limits for Dental Services |
| 471-000-73 | Form MS-6, "Ambulatory Room and Board Agreement", and Completion Instructions |
| 471-000-74 | Transportation Provider Requirements |
| 471-000-75 | Nebraska Medicaid Billing Instructions for Completing Form MC-82-AD, "Adult Day Care nursing/Aide Services Claim Form" for Private Duty Nursing or Personal Assistance Services in Adult Day Care Centers |
| 471-000-76 | Billing Instructions for Federally Qualified Health Center Services |
| 471-000-77 | Billing Instructions for Rural Health Clinic Services |
| 471-000-78 | Nebraska Medicaid Form Locator Requirements for Form CMS-1450 (UB-04) |
| 471-000-79 | Form EA-160, "Record of Health Cost - Share of Cost - Medicaid Program", and Completion Instructions |
| 471-000-80 | Form MS-66, "Medicaid Mental Health Transporation Services Authorization and Claim Form", and Completion Instructions |
| 471-000-81 | Nebraska Medicaid Billing Instructions for Hospice Services |
| 471-000-82 | Instructions for Completing Turnaround MC-4, "Long Term Care Facility Turnaround Billing Document" |
| 471-000-83 | Billing Instructions for Hospital Services |
| 471-000-84 | Form MC-6, "Physician's Certification Form", and Completion Instructions |
| 471-000-85 | Explanation of Remittance Advice and Refund Requests Report |
| 471-000-86 | Example of Form MC-38, "Notice of Lock-In Finding" |
| 471-000-87 | Example of Form MC-2, "Electronic Attachment Control Number Form" |
| 471-000-88 | Nebraska Medicaid Dental Program Completion Instructions for the 2006, 2002, 1999 and 1994 ADA Dental Claim Forms |
| 471-000-89 | Form MC-14, "Confidential Report", and Completion Instructions |
| 471-000-90 | Form MC-19, "Medical Assistance Provider Agreement", and Completion Instructions |
| 471-000-91 | Form MC-20, "Medicaid Hospital Provider Agreement", and Completion Instructions |
| 471-000-92 | Instructions for Completing Form MC-37, "Home Care Time Sheet" |
| 471-000-93 | Instructions for Completing Form MC-66, "Recipient Choice of Provider Agreement" |
| 471-000-94 | Instructions for Completing Form MC-84, "Personal Care Aide Provider Check List" |
| 471-000-95 | Instructions for Completing Form MC-73, "Personal Care Services - Care Plan" |
| 471-000-96 | Form MC-83, "Mental Health/Substance Abuse Treatment Planning Document for Outpatient Services", and Completion Instructions |
| 471-000-97 | Instructions for Completing Form HHS-100 "Private Duty" Nursing Notes |
| 471-000-98 | (Reserved) |
| 471-000-99 | Form MC-11D, "Return of Warrant", and Medicaid Claim Adjustments and Refund Procedures |
| 471-000-100 | Form MCP575, "Casualty Insurance Policy Information Sheet" |
| 471-000-101 | Explanation of Form MC-85, "Supplemental Explanation of Medicaid Benefits" |
| 471-000-102 | Form MC-9, "Prior Authorization Document," and Completion Instructions for IMD's |
| 471-000-103 | Form HHS-6, "Notice of Action," and Completion Instructions |
| 471-000-104 | Instructions for Completing Form MC-81, "Medical Assistance Long Term Care Provider Agreement" |
| 471-000-105 | Instructions for Completing Form MILTC-9, "Service Provider Agreement" |
| 471-000-106 | Form MILTC-4B, "Provider Authorization Notice," and Completion Instructions |
| 471-000-107 | Form MILTC-4D, "Physcian/RN Statement for Health Maintenance Activities," and Completion Instructions |
| 471-000-108 | Form HHS-4C, "Provider Notice" and Completion Instructions |
| 471-000-109 | Form MMS-100, "Sterilization Consent Form", and Completion Instructions |
| 471-000-110 | Form MMS-101, "Informed Consent for Hysterectomies", and Completion Instructions |
| 471-000-111 | (Reserved) |
| 471-000-112 | IRS Form 2678, "Employer Appointment of Agent," and Completion Instructions |
| 471-000-113 through 120 | (Reserved) |
| 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) |
| 471-000-125 | (Reserved) |
| 471-000-126 | Procedure Codes Subject to Copayment Requirements |
| 471-000-127 | Instructions for Explanation of Deleted Medicaid Claims Weekly Report (MCP564-D) |
| 471-000-128 | Instructions for Explanations of Medicaid Claims in Process Over 30 Days Report (MCP564-S) |
| 471-000-129 | Instructions for Explanation of Deleted Medicaid Claims and Medicaid Claims in Process Over 30 Days Report (MCP564-DS) |
| 471-000-130 through 200 | (Reserved) |
| 471-000-201 | Instructions for Completing Form MC-9D, "Dental Treatment and Prior Authorization" |
| 471-000-202 | Income Levels for Medical Assistance for Presumptive Eligibility for Pregnant Women |
| 471-000-203 | Instructions for Completing Form MC-9NF, "Prior Authorization for Nursing Facility Care" |
| 471-000-204 | (Reserved) |
| 471-000-205 | Form MC-9S, "Prior Authorization Document for Hearing Aids", and Completion Instructions |
| 471-000-206 | Form MS-77, "Request for Prior Authorization," and Completion Instructions |
| 471-000-207 | Instructions for Completing Form MS-78, "Augmentative Communication Device Selection Report" |
| 471-000-208 | Form MS-79, "Wheelchairs and Wheelchair Seating System Equipment Selection Report," and Completion Instructions |
| 471-000-209 | Form MS-80, "Air Fluidized and Low Air Loss Bed Certification of Medical Necessity," and Completion Instructions |
| 471-000-210 | (Reserved) |
| 471-000-211 | Form MC-10, "Prior Authorization Document Adjustment", and Completion Instructions |
| 471-000-212 through 219 | (Reserved) |
| 471-000-220 | Instructions for Completing Form DSS-14AD, "Functional Criteria" |
| 471-000-221 | Instructions for Completing Form DM-5, "Physician's Confidential Report," for the Preadmission Screening Process (PASP) |
| 471-000-222 | Instructions for Completing Form DM-5-LTC, "Long Term Care Evaluation" for the Preadmission Screening Process (PASP) |
| 471-000-223 | Instructions for Completing Form DPI-OBRA1, "Identification Screen" |
| 471-000-224 | Instructions for Completing Form DPI-OBRA2, "Evaluation and Service Recommendation" |
| 471-000-225 | Instructions for Completing Form DPI-OBRA2 MR/RC, "Evaluation and Service Recommendation" – MR/RC |
| 471-000-226 | Instructions for Completing Form DPI-OBRA1a, "Categorical Determination and Exemption" |
| 471-000-227 | Instructions for Completing Form DPI-OBRA5, "Notice of PASARRP Findings" |
| 471-000-228 | Instructions for Completing Form DPI-OBRA6, "Assurances" |
| 471-000-229 | Instructions for Completing Form DPI-OBRA7, "Referral for Community-Based Services" |
| 471-000-230 | Instructions for Completing Form DPI-OBRA8, "Authorization for Release of Information" |
| 471-000-231 | Instructions for Completing Form DPI-OBRA-9, "PASARRP Summary of Findings Report" |
| 471-000-232 | (Reserved) |
| 471-000-233 | Qualified Mental Retardation Professional (42 CFR 483.430) |
| 471-000-234 | Guidelines for Social History |
| 471-000-235 through 300 |
(Reserved) |
Charts and Examples |
|
| 471-000-301 through 302 |
(Reserved) |
| 471-000-303 | Form MS-91, "Presumptive Application for Pregnant Women" |
| 471-000-304 through 405 | (Reserved) |
| 471-000-406 | Orthodontic Diagnostic Score Sheet and Other Information |
| 471-000-407 and 408 |
(Reserved) |
| 471-000-409 | Ambulatory Surgery Center Rates |
| 471-000-410 through 503 | (Reserved) |
| 471-000-504 | Nebraska Medicaid Practitioner Fee Schedule for Ambulance Services |
| 471-000-505 | Nebraska Medicaid Practitioner Fee Schedule for Chiropractic Services |
| 471-000-506 | Nebraska Medicaid Practitioner Fee Schedule for Dental Services |
| 471-000-507 | Nebraska Medicaid Practitioner Fee Schedule for Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics |
| 471-000-508 | Nebraska Medicaid Practitioner Fee Schedule for Hearing Aid Services |
| 471-000-509 | Nebraska Medicaid Home Health Agency Fee Schedule |
| 471-000-510 through 512 | (Reserved) |
| 471-000-513 | Nebraska Medicaid RN/LPN Fee Schedule |
| 471-000-514 | (Reserved) |
| 471-000-515 | Nebraska Medicaid Personal Care Aide Fee Schedule |
| 471-000-516 | (Reserved) |
| 471-000-517 | Nebraska Medicaid Practitioner Fee Schedule for Physical Therapy and Occupational Therapy |
| 471-000-518 | Nebraska Medicaid Practitioner Fee Schedule for Physician Services |
| 471-000-519 | Nebraska Medicaid Practitioner Fee Schedule for Podiatry Services |
| 471-000-520 through 522 | (Reserved) |
| 471-000-523 | Nebraska Medicaid Practitioner Fee Schedule for Speech Pathology and Audiology |
| 471-000-524 | Nebraska Medicaid Practitioner Fee Schedule for Visual Care Services |
| 471-000-525 through 531 | (Reserved) |
| 471-000-532 | Nebraska Medicaid Practitioner Fee Schedule for Mental Health and Substance Abuse Services |
| 471-000-533 | Nebraska Medicaid Practitioner Fee Schedule for HEALTH CHECK Services |
| 471-000-534 through 535 | (Reserved) |
| 471-000-536 | Nebraska Medicaid Hospice Fee Schedule |
| 471-000-537 through 539 | (Reserved) |
| 471-000-540 | Nebraska Medicaid Practitioner Fee Schedule for Injectables |
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