Skip to main content

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

contact-us

Need help? We're here for you.

Contact Us
Last Updated On: 2/4/2019
Medicare and Prescription Drug Plan Members: The new and enhanced member portal is here! This portal offers a fresh homepage, all new billing and payment options for 2020, and more! Login to your portal today. ×