Nebraska Medicaid Program – Documents
If you are interested in participating in this new Medicaid program, you must have, or obtain, a Nebraska Medicaid Provider Identification number.
For your convenience, each form is available in (PDF) format for you to print or download.
National Provider Identifier (NPI) Application:
Providers across all specialty lines are required to have a NPI number. If you have not already done so, click this link to be connected to the National Plan & Provider Enumeration System (NPPES) web site to apply for your NPI number. Get Form
Avesis Eye Medical Provider Application
Ophthalmologists new to Avesis or who have not completed an application within the past thirty (30) months should complete a new application. Get Form
Avesis Routine Eye Care Provider Application
Providers new to Avesis or who have not completed an application within the past thirty (30) months should complete a new application. Get Form
Avesis Routine/Eye Medical Provider Agreement
The Provider Agreement outlines the contractual arrangement between "the ophthalmologist" and Avesis. Get Form
Addendum to Provider Agreement
The Addendum to the Eye Medical and Eye Care Provider Agreement has been updated. Get Form
Electronic Funds Transfer (EFT)
EFT is available to providers on this panel who are utilizing electronic mediums for eligibility verification and claims submission. Get Form
If you have any questions please contact one of our Provider Recruitment Specialists at 800-643-1132 Extension: 116 or 141.