Nebraska Medicaid Billing Provider Trading Partner Authorization
Fax the form to (402) 742-2353; OR
Email to
; OR
Mail to:
Department of Health and Human Services
Attn: Medicaid EDI Help Desk
PO Box 95026
Lincoln, NE 68509-5023
Standard processing time is 5 business days
Email and ask if you have been linked to Office Allys Submitter ID 6279
Once you receive confirmation that you have been linked to Office Ally, you MUST email
with the below information PRIOR to submitting claims electronically
Email Subject: Medicaid Nebraska (MCDNE) EDI Approval
Body of Email:
Please log my EDI approval for Medicaid Nebraska.
o Provider Name
o Tax ID
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
Nebraska Department of Health and Human Services
Please note form fields with an * are required fields that MUST be completed.
This Authorization is required of all Nebraska Medicaid Providers who wish to submit or receive electronic transactions
directly or through a third party, such as a clearinghouse, to Nebraska Medicaid (hereinafter known as “NE Medicaid”).
The submitter of such transactions is hereinafter known as “Trading Partner.
l NE Medicaid will only exchange transactions with an approved Trading Partner when an Authorization is on file from
a NE Medicaid provider.
l The Authorization must list the specific NPI, Taxonomy and Zip+4 for each NE Medicaid Health Care Provider, or the
specific provider number for each NE Medicaid Atypical Provider, transaction(s) and the effective start date(s) of the
l When a Trading Partner is no longer authorized for any or all of the provider numbers and/or transactions listed, a
new Authorization must be completed providing the End Date(s).
l Only one Trading Partner can be authorized per transaction at a time and the authorized dates may not overlap.
l NOTE: When authorizing for multiple provider numbers/entities, if the transaction(s) or effective date(s) information
varies for provider numbers/entities, please complete separate Authorizations.
*With this understanding, I,______________________________________________ ___________________________,
(*Name) (Title)
(*Provider Name)
(*Trading Partner)
To submit and/or receive the electronic transactions indicated below on behalf of the listed NE Medicaid
Providers for the dates indicated:
When authorizing for a NE Medicaid Health Care Provider(s) the following fields are required:
*Provider Name *NPI Number *Taxonomy *Zip + 4
__ __ __ __ __+__ __ __ __
__ __ __ __ __+__ __ __ __
__ __ __ __ __+__ __ __ __
__ __ __ __ __+__ __ __ __
When authorizing for a NE Medicaid Atypical Provider(s) the following fields are required:
*Provider Name *Medicaid Provider Number
(Note: Please attach a separate sheet for additional provider(s), if necessary)
MS-85 (19041) 4/14 Page 1 of 35010 Nebraska Medicaid Billing Provider Trading Partner Authorization
Office Ally
Submit/Receive 5010 Transactions with Nebraska Medicaid:
Note for each transaction:
l The Start Date is the date upon which NE Medicaid can start accepting that transaction.
l The End Date is the last date upon which a transaction can be accepted.
l The End Date is not required until applicable.
Start Date
End Date
837 Professional Claim
837 Institutional Claim
837 Dental Claim
270/271 Eligibility Inquiry / Response
276/277 Claim Status Request / Response
278 Prior Authorization Inquiry / Response
Trading Partners will receive a weekly Electronic Claims Activity (ECA) Report, 999, and a TA1 (if requested) Functional
Acknowledgements for submitted files; therefore, Providers will not select an ECA or 277CA acknowledgement.
Providers will receive the selection made by their Trading Partners.
A start date is required for each 5010 transaction selected. Note that EDI enrollment cannot be backdated; however,
claims can be submitted with dates of service within the timely filing requirements (currently six months per
Provider Bulletin 13-50 ).
NOTE: Electronic Fund Transfer (EFT) enrollment is required when a provider enrolls with Nebraska Medicaid.
To receive the 835 Remittance Advice / Refund Requests Report, please complete the 5010 Nebraska Medicaid
Trading Partner Authorization and Enrollment for Electronic Remittance Advice (ERA) 835 Transaction form.
This form can be found on our EDI Web site at:
When receiving the 835, the Refund Requests Report will be provided electronically.
MS-85 Page 2 of 35010 Nebraska Medicaid Billing Provider Trading Partner Authorization
By signing or completing “Name of Person Submitting Enrollment” the submitting individual is attesting and
acknowledging on behalf of the Nebraska Medicaid Provider(s) listed above that:
l he or she is authorized to complete and sign this Authorization;
l the information provided is accurate and true;
l electronic submission of claims through a Trading Partner constitutes certification as required by 471 NAC
l the Trading Partner is responsible to communicate to the Provider any problems or delays in transmission, as
well as error/reject information or reports that the provider needs in order to correct, track or complete
l Nebraska Medicaid will not exchange transactions with a Trading Partner on behalf of a Provider without this
Trading Partner Authorization;
l the Trading Partner must have an active Trading Partner Agreement with Nebraska Medicaid, or this
Authorization is null and void;
l Any changes to the Provider’s NPI, Taxonomy and/or Zip Code +4 will require an updated 5010 NE
Medicaid Billing Provider Trading Partner Authorization; and
l this information will be kept current by completing new Authorizations as necessary.
Type or Printed:
*Name of Person Submitting Enrollment:
*Provider / Office Name:
*City, State, Zip:
*Phone Number:
Email Address:
If you are switching from one Trading Partner to another, please indicate your previous Trading Partner to discontinue
submission of the above transactions.
Discontinue Trading Partner (Name)
Please complete and submit this form to Nebraska Medicaid. If using a Trading Partner, you may be requested to
return this form to the Trading Partner. If submitting this form directly to Nebraska Medicaid, send as an attachment to or fax or mail to:
FAX: 402-742-2353 Mail: Phone 402-471-9461 (In Lincoln)
Department of Health and Human Services 866-498-4357 (Outside of Lincoln)
Attn: Medicaid EDI Help Desk
PO BOX 95026
Lincoln, NE 68509-5026
If you have questions, please contact the Nebraska Medicaid EDI Help Desk at:
Please be sure to save your document then attach to email.
MS-85 Page 3 of 35010 Nebraska Medicaid Billing Provider Trading Partner Authorization
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