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Medicaid Providers

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Forms

Administrative

This form can be used to record mileage for member reimbursement.

Authorizations

Drug Prior Authorization Requests Supplied by the Physician/Facility

Nebraska Department of Health and Human Services Medicaid and Long-Term Care - HERITAGE HEALTH Prior Authorization for Hearing Aids

Nebraska Home Health Prior Authorization Request Form

Save time! Submit and review your requests online @ https://provider.wellcare.com

Behavioral Health

Claims

Refund Check Information Sheet* (RCIS)

Pharmacy

Nebraska Medicaid and Long-Term Care Informed Consent Form for Treatment of Opioid Use Disorder To be completed upon initiation of therapy with Buprenorphine/Naloxone or Buprenorphine

Drug Prior Authorization Requests Supplied by the Physician/Facility

Please complete and submit this form to request coverage through the WellCare of Nebraska Medicaid plan.

Nebraska Tobacco Quitline

Other Forms

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Last Updated On: 2/4/2019
Keep you and your family healthy. Members can learn more about the 2019-nCoV (Novel Coronavirus) at https://www.cdc.gov/coronavirus/2019-ncov/index.html ×