Provider Type. Enter the appropriate PROVIDER TYPE that corresponds with the Provider Type Code entered in 10a. Type Code (field 10a) Program Type of Provider (field 10b) 48 Medicaid Adult Substance Abuse 30 Medicaid Adult Day Care - Bath Services, Registered Nurse MS-84 9 Medicaid Ambulatory Surgical Center (ASC) Copy of License; MS-84 15 Medicaid Anesthesiologist Copy of License; MS-84 41 Medicaid Assertive Community Treatment (ACT MRO Program MS-84 68 Medicaid Audiologist Copy of License; MS-84; 83 Medicaid Autism Waiver - Applied Behavioral Analysis Technician MS-84 Medicaid Autism Waiver - EIBI Autism Waiver FA-84 83 Medicaid Autism Waiver - Lead Therapist MS-84 83 Medicaid Autism Waiver - Supervising Behavioral Therapist MS-84 5 Medicaid Chiropractor Copy of License; MS-84 12 Medicaid Clinic - Hospital Based, Licensed Mental Centers MS-84; 13 Medicaid Clinic - Professional (PC) MS-84 44 Medicaid Community Support (CSW) MRO Program MS-84; 45 Medicaid Day Rehabilitation (DAYR) MRO Program MS-84; 77 Medicaid Day Treatment Provider (DAY) MS-84; 40 Medicaid Dentist (DDS) Copy of License; MS-84 21 Medicaid Dispensing Physician (MD) Copy of License; MS-84 61 Medicaid Emergency Transportation MS-84 17 Medicaid Federally Qualified Health Center (FQHC) MS-84; CMS Documentation of Status; Out of State rate letter 60 Medicaid Hearing Instrument Specialist (HEAR) MS-84 14 Medicaid Home Health Agency (HHAG) MS-84 59 Medicaid Hospice (HSPC) MS-84 10 Medicaid Hospital Copy of License; CLIA certification; CMS-1539 25 Medicaid Indian Health Hospital Clinic (IHSH) SSA-1539; MS-84 16 Medicaid Laboratory (Independent) CMS-1539 42 Medicaid Licensed Dental Hygienist (LDH) Copy of License; MS-84 78 Medicaid Licensed Drug & Alcohol Counselor (LDAC) Copy of License; MS-84 39 Medicaid Licensed Independent Mental Health Practi- tioner (LIMHP) Copy of License; MS-84; 63 Medicaid Licensed Medical Nutrition Therapist (LMNT) Copy of License; MS-84; list of specific services providing 36 Medicaid Licensed Mental Health Practitioner (LMHP) Copy of License; MS-84; 31 Medicaid Licensed Practical Nurse (LPN) Copy of License; MS-84 67 Medicaid Licensed Psychologist (PHD) Copy of License; MS-84; 69 Medicaid Medicaid in Public Schools (MIPS) Occupational Therapist Copy of License; MS-84 32 Medicaid Medicaid in Public Schools (MIPS) Physical Therapist Copy of License; MS-84 68 Medicaid Medicaid in Public Schools (MIPS) Speech Pathologist Copy of License; MS-84 35 Medicaid Direct Care Staff MS-84; 34 Medicaid Community Treatment Aid MS-84; 37 Medicaid Provisional Mental Health Professional/ Masters Level Equivalent (MHP) Copy of License; MS-84 Type Code (field 10a) Program Type of Provider (field 10b) 61 Medicaid Non-Emergency Transportation (NET) Copy of License; MS-84 28 Medicaid Nurse Midwife (NW) Copy of License; MS-84 29 Medicaid APRN-Nurse Practitioner Copy of License; Copy of National Specialty Certification; MS-84; 11 Medicaid Nursing Facility Copy of License; MS-84 11 Medicaid Nursing Facility - Hospice in Nursing Facility Copy of License; MS-84 69 Medicaid Occupational Therapist Copy of License; MS-84 66 Medicaid Optical Supplier (OPTC) MS-84 6 Medicaid Optometrist Copy of License; MS-84 65 Medicaid Orthopedic Device Supplier (▇▇▇▇) MS-84 50 Medicaid Pharmacy - Home Therapy, Independent, Professional, Small or Large Chain, Nursing Facility, or Other Copy of License; MS-84; Mail Order Pharmacies must attach a copy of their mail order permit 49 Medicaid Pharmacist-Tobacco Cessation Counselor Copy of License; MS-84 22 Medicaid Physician Assistant (PA) Copy of License; MS-84 2 Medicaid Physician, DO Copy of License; MS-84 1 Medicaid Physician, MD Copy of License; MS-84 7 Medicaid Podiatrist (DPM) Copy of License; MS-84 58 Medicaid Provisionally Licensed Drug & Alcohol Coun- selors (PDAC) Copy of License; MS-84; 57 Medicaid Provisionally Licensed PHD - PPHD Copy of License; MS-84; 30 Medicaid Registered Nurse (RN) Copy of License; MS-84 32 Medicaid Registered Physical Therapist (RPT) Copy of License; MS-84 62 Medicaid Rental & Retail Supplier MS-84 46 Medicaid Residential Rehabilitation (REST) MS-84; 87 Medicaid Psychiatric Residential Treatment Facility (PRTF) MS-84; 20 Medicaid Rural Health Clinic - Independent MS-84 23 Medicaid Rural Health Clinic - Provider Based (Over 50 Beds) MS-84; CMS Documentation of Status; Out of State rate letter 19 Medicaid Rural Health Clinic-Provider Based (Less than 50 beds) MS-84; CMS Documentation of Status; Out of State rate letter 64 Medicaid Specially Licensed PHD/Psychology Resi- dent (SPHD) Copy of License; MS-84; 68 Medicaid Speech Pathologist Copy of License; MS-84 47 Medicaid Substance Abuse Treatment Center (SATC) MS-84; 79 Medicaid Treatment Crisis Intervention (TCI) MS-84; 86 Medicaid Professional Resource Family Care MS-84; 81 Medicaid Therapeutic Group Home (TRGH) MS-84; 26 Medicaid Tribal 638 Clinic (T638) MS-84 4475 Medicaid Personal Assistance Services FA-84 - Agencies; FA-100 - Individuals; MC-190; MC-199 9245 Medicaid - AD Waiver Adult Day Health FA-84; MC-190; MC-199 9704 Medicaid - AD Waiver Child Care for Children with Disabilities MCFA-84 - Agencies; FA-100 - Individuals; MC-190; MC-199 1691 Medicaid - AD Waiver Home Care/Chore FA-84 - Agencies; FA-100 - Individuals; MC-190; MC-199 9040 Medicaid - AD Waiver Home Delivered Meals FA-84; MC-190; MC-199 8382 Medicaid - AD Waiver Independence Skills Management FA-84 - Agencies; FA-100 - Individuals; MC-190; MC-199 61 Medicaid - AD Waiver Non-Emergency Transportation (NET) MS-84; MC-190; MC-199 2500 Medicaid - AD Waiver Child Care for Children with Disabilities In-Home FA-84; MC-190; MC-199 Type Code (field 10a) Program Type of Provider (field 10b) 9233 Medicaid - AD Waiver Independence Skills Management In-Home FA-84; MC-190; MC-199 1113 Medicaid - AD Waiver Respite Care Income FA-84; MC-190; MC-199 5390 Medicaid - AD Waiver Nutrition Services FA-84 - Agencies; FA-100 - Individuals; MC-190, MC-199 3447 Medicaid - AD Waiver Personal Emergency Response System FA-84; MC-190; MC-199 7395 Medicaid - AD Waiver Respite Care FA-84 - Agencies; FA-100 - Individuals; MC-190; MC-199 11 Medicaid - AD/TBI Waiver Assisted Living MS-84; MC-190; MC-199 9539 Medicaid - DD Waiver Community Living & Day Support FA-84 - Agencies; FA-100 - Individuals 1398 Medicaid - DD Waiver Home Modification FA-84 - Agencies; FA-100 - Individuals 7599 Medicaid - DD Waiver Homemaker FA-84 - Agencies; FA-100 - Individuals 3447 Medicaid - DD Waiver Personal Emergency Response System FA-84 - Agencies; FA-100 - Individuals 7395 Medicaid - DD Waiver Respite FA-84 - Agencies; FA-100 - Individuals Medicaid - DD Waiver Specialized Residential Services FA-84 - Agencies; FA-100 - Individuals Medicaid - DD Waiver Specialized Day Services FA-84 - Agencies; FA-100 - Individuals 6995 Medicaid - DD Waiver Vehicle Modifications FA-84 - Agencies; FA-100 - Individuals 4479 Medicaid - DD Waiver Adult Companion Service FA-84 - Agencies; FA-100 - Individuals 2546 Medicaid - DD Waiver Adult companion Service In-Home FA-84 - Agencies; FA-100 - Individuals 6221 Medicaid - DD Waiver Adult Day Services FA-84 - Agencies; FA-100 - Individuals 7783 Medicaid - DD Waiver Consultative Assessment Service FA-84 - Agencies; FA-100 - Individuals 4428 Medicaid - DD Waiver Crisis Intervention Support FA-84 - Agencies; FA-100 - Individuals 6845 Medicaid - DD Waiver Habilitative Community Inclusion FA-84 - Agencies; FA-100 - Individuals 5416 Medicaid - DD Waiver Habilitative Workshop FA-84 - Agencies; FA-100 - Individuals 8362 Medicaid - DD Waiver Prevocational Services FA-84 - Agencies; FA-100 - Individuals 2656 Medicaid - DD Waiver Respite - Agency FA-84 - Agencies; FA-100 - Individuals 8148 Medicaid - DD Waiver Respite - Independent In-Home FA-84 - Agencies; FA-100 - Individuals 9042 Medicaid - DD Waiver Respite - Independent - Out FA-84 - Agencies; FA-100 - Individuals 9695 Medicaid - DD Waiver Supported Employment - Individual FA-84 - Agencies; FA-100 - Individuals 8264 Medicaid - DD Waiver Support Employment - Enclave FA-84 - Agencies; FA-100 - Individuals 2141 Medicaid - DD Waiver Supported Employment - Follow Along FA-84 - Agencies; FA-100 - Individuals 3764 Medicaid - DD Waiver Transportation FA-84 - Agencies; FA-100 - Individuals Type Code (field 10a) Program Type of Provider (field 10b) 7835 Medicaid - DD Waiver Transitional Services FA-84 - Agencies; FA-100 - Individuals 2633 Medicaid - DD Waiver Environmental Modification Assessment FA-84 - Agencies; FA-100 - Individuals 9769 Medicaid - DD Waiver Homemaker - Agency FA-84 - Agencies; FA-100 - Individuals 9393 Medicaid - DD Waiver Homemaker - Independent FA-84 - Agencies; FA-100 - Individuals 2611 Medicaid - DD Waiver In-Home Res Habilitation FA-84 - Agencies; FA-100 - Individuals 9844 Medicaid - DD Waiver Residential Habilitation FA-84 - Agencies; FA-100 - Individuals 3447 Medicaid - DD Waiver Emergency Response System FA-84 - Agencies; FA-100 - Individuals 9418 Medicaid - DD Waiver Assistive Technology and Supports FA-84 - Agencies; FA-100 - Individuals Medicaid- MFP Transistion Planning and Support (TPS) FA-84 - Agencies; FA-100 - Individuals entered in 11a. Primary Specialty Code (11a) Primary Specialty Description Primary Specialty Code (11a) Primary Specialty Description 01 General Practice 48 Podiatrist - Surgical Chiropodist 02 General Surgery 49 Miscellaneous-MIPS, Ambulatory Surgical Center, Etc 03 Allergy 50 Reserved 04 Otology, Laryngology, Rhinology (ENT) 51 Medical Supply Company with Certified Orthotist (CO) Certification 05 Anesthesiology 52 Medical Supply Company with Certified Prosthetist (CP) Certifica- tion 06 Cardiovascular Disease 53 Medical Supply Company with Certified Orthotist-Prosthetist (CPO) Certification 07 Dermatology 54 Medical Supply Company not included in 51, 52, or 53 08 Family Practice 55 Individual Certified Orthotist (CO) 09 Reserved 56 Individual Certified Prosthetist (CP) 10 Gastroenterology 57 Individual Certified Orthotist-Prosthetist (CPO) 11 Internal Medicine (Includes Geriatrics & Nephrology) 58 Individual not included in 55, 56, or 57 12 Internal Medicine (Restricted to group with multi spe- cialties) 59 Ambulance 13 Neurology 60 Public Health or Welfare Agencies (Federal, State & Local) 14 Neurological Surgery 61 Voluntary Health or Charitable Agencies 15 Reserved 62 Licensed Psychologist (Clinical) 16 OB/GYN 63 Portable X-ray supplier (Billing Independently) 17 Ophthamology, Otology, Laryngology, Rhinology (EENT) 64 Audiologists (Billing Independently) 18 Ophthamology 65 Physical Therapist (Billing Independently) 19 Oral Surgery (Dentist only) 66 Hospitals 20 Orthopedic Surgery 67 Urgent Cared Health Plan (OPHP) 21 Reserved 68 Dialysis 23 Peripheral Vascular Disease or Surgery 70 Clinic 24 Plastic Surgery 71 Diagnostic X-ray Clinic 25 Physical Medicine & Rehabilitation 72 Diagnostic Laboratory Clinic 26 Psychiatry/Mental Health/Substance Abuse 73 Physiotherapy 28 Proctology 74 Occupational Therapy 29 Pulmonary Disease 75 Assisted Living Services 30 Radiology - X-ray 76 Other Physician Specialist for HEALTH CHECK Follow-up 32 Radiation Therapy 77 Other Provider (non-MD) for HEALTH CHECK Follow-up 33 Thoracic Surgery 78 Screening Physician & Other Physician Specialist for HEALTH CHECK Follow-up 34 Urology 79 Adult Day Care 35 Chiropractor 80 Rehab Providers (MRO) (DPI) 36 Nuclear Medicine (MD only) 81 Rehab Acute Hospital 37 Pediatrics 82 Hospice 38 Endocrinology, Diabetes 87 All Other-Including AD Waiver 39 Gerontology 88 Unknown - Suppliers 40 Hand Surgery 89 Chemical Dependency 41 Oncology/Hematology 90 Nurse Midwife 42 Epidemiology/Infectious Disease 91 Nurse Practitioner 43 Certified Registered Nurse Anesthetist (CRNA) 94 PSC Exempt (Public Transportation) Primary Specialty Code (11a) Primary Specialty Description Primary Specialty Code (11a) Primary Specialty Description 44 Nephrology 95 Commercial NET (Licensed by the Public Service Commission) 45 Neonatology 96 Individual NET (Friend, neighbor or family member who is not legally responsible for the client or in the business of transporta- tion for hire). 46 Rheumatology 99 Unknown - Practitioners 47 Physiological Labs (Independent)
Appears in 1 contract
Sources: Nebraska Service Provider Agreement
Provider Type. Enter the appropriate PROVIDER TYPE that corresponds with the Provider Type Code entered in 10a. Type Code (field 10a) Program Type of Provider (field 10b) 48 Medicaid Adult Substance Abuse 30 Medicaid Adult Day Care - Bath Services, Registered Nurse MS-84 9 Medicaid Ambulatory Surgical Center (ASC) Copy of License; MS-84 15 Medicaid Anesthesiologist Copy of License; MS-84 41 Medicaid Assertive Community Treatment (ACT MRO Program MS-84 68 Medicaid Audiologist Copy of License; MS-84; 83 Medicaid Autism Waiver - Applied Behavioral Analysis Technician MS-84 Medicaid Autism Waiver - EIBI Autism Waiver FA-84 83 Medicaid Autism Waiver - Lead Therapist MS-84 83 Medicaid Autism Waiver - Supervising Behavioral Therapist MS-84 5 Medicaid Chiropractor Copy of License; MS-84 12 Medicaid Clinic - Hospital Based, Licensed Mental Centers MS-84; 13 Medicaid Clinic - Professional (PC) MS-84 44 Medicaid Community Support (CSW) MRO Program MS-84; 45 Medicaid Day Rehabilitation (DAYR) MRO Program MS-84; 77 Medicaid Day Treatment Provider (DAY) MS-84; 40 Medicaid Dentist (DDS) Copy of License; MS-84 21 Medicaid Dispensing Physician (MD) Copy of License; MS-84 61 Medicaid Emergency ▇▇-▇▇ ▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ Transportation MS-84 17 Medicaid Federally Qualified Health Center (FQHC) MS-84; CMS Documentation of Status; Out of State rate letter 60 Medicaid Hearing Instrument Specialist (HEAR) MS-84 14 Medicaid Home Health Agency (HHAG) MS-84 59 Medicaid Hospice (HSPC) MS-84 10 Medicaid Hospital Copy of License; CLIA certification; CMS-1539 25 Medicaid Indian Health Hospital Clinic (IHSH) SSA-1539; MS-84 16 Medicaid Laboratory (Independent) CMS-1539 42 Medicaid Licensed Dental Hygienist (LDH) Copy of License; MS-84 78 Medicaid Licensed Drug & Alcohol Counselor (LDAC) Copy of License; MS-84 39 Medicaid Licensed Independent Mental Health Practi- tioner (LIMHP) Copy of License; MS-84; 63 Medicaid Licensed Medical Nutrition Therapist (LMNT) Copy of License; MS-84; list of specific services providing 36 Medicaid Licensed Mental Health Practitioner (LMHP) Copy of License; MS-84; 31 Medicaid Licensed Practical Nurse (LPN) Copy of License; MS-84 67 Medicaid Licensed Psychologist (PHD) Copy of License; MS-84; 69 Medicaid Medicaid in Public Schools (MIPS) Occupational Therapist Copy of License; MS-84 32 Medicaid Medicaid in Public Schools (MIPS) Physical Therapist Copy of License; MS-84 68 Medicaid Medicaid in Public Schools (MIPS) Speech Pathologist Copy of License; MS-84 35 Medicaid Direct Care Staff MS-84; 34 Medicaid Community Treatment Aid MS-84; 37 Medicaid Provisional Mental Health Professional/ Masters Level Equivalent (MHP) Copy of License; MS-84 Type Code ▇▇-▇▇ ▇▇▇▇ ▇▇▇▇ (field 10a▇▇▇▇▇ ▇▇▇) Program Type of Provider (field 10b) 61 Medicaid Non-Emergency Transportation (NET) Copy of License; MS-84 28 Medicaid Nurse Midwife (NW) Copy of License; MS-84 29 Medicaid APRN-Nurse Practitioner Copy of License; Copy of National Specialty Certification; MS-84; 11 Medicaid Nursing Facility Copy of License; MS-84 11 Medicaid Nursing Facility - Hospice in Nursing Facility Copy of License; MS-84 69 Medicaid Occupational Therapist Copy of License; MS-84 66 Medicaid Optical Supplier (OPTC) MS-84 6 Medicaid Optometrist Copy of License; MS-84 65 Medicaid Orthopedic Device Supplier (▇▇▇▇) MS-84 50 Medicaid Pharmacy - Home Therapy, Independent, Professional, Small or Large Chain, Nursing Facility, or Other Copy of License; MS-84; Mail Order Pharmacies must attach a copy of their mail order permit 49 Medicaid Pharmacist-Tobacco Cessation Counselor Copy of License; MS-84 22 Medicaid Physician Assistant (PA) Copy of License; MS-84 2 Medicaid Physician, DO Copy of License; MS-84 1 Medicaid Physician, MD Copy of License; MS-84 7 Medicaid Podiatrist (DPM) Copy of License; MS-84 58 Medicaid Provisionally Licensed Drug & Alcohol Coun- selors (PDAC) Copy of License; MS-84; 57 Medicaid Provisionally Licensed PHD - PPHD Copy of License; MS-84; 30 Medicaid Registered Nurse (RN) Copy of License; MS-84 32 Medicaid Registered Physical Therapist (RPT) Copy of License; MS-84 62 Medicaid Rental & Retail Supplier MS-84 46 Medicaid Residential Rehabilitation (REST) MS-84; 87 Medicaid Psychiatric Residential Treatment Facility (PRTF) MS-84; 20 Medicaid Rural Health Clinic - Independent MS-84 23 Medicaid Rural Health Clinic - Provider Based (Over 50 Beds) MS-84; CMS Documentation of Status; Out of State rate letter 19 Medicaid Rural Health Clinic-Provider Based (Less than 50 beds) MS-84; CMS Documentation of Status; Out of State rate letter 64 Medicaid Specially Licensed PHD/Psychology Resi- dent (SPHD) Copy of License; MS-84; 68 Medicaid Speech Pathologist Copy of License; MS-84 47 Medicaid Substance Abuse Treatment Center (SATC) MS-84; 79 Medicaid Treatment Crisis Intervention (TCI) MS-84; 86 Medicaid Professional Resource Family Care MS-84; 81 Medicaid Therapeutic Group Home (TRGH) MS-84; 26 Medicaid Tribal 638 Clinic (T638) MS-84 4475 Medicaid Personal Assistance Services FA-84 - Agencies; FA-100 - Individuals; MC-190; MC-199 9245 Medicaid - AD Waiver Adult Day Health FA-84; MC-190; MC-199 9704 Medicaid - AD Waiver Child Care for Children with Disabilities MCFA-84 - Agencies; FA-100 - Individuals; MC-190; MC-199 1691 Medicaid - AD Waiver Home Care/Chore FA-84 - Agencies; FA-100 - Individuals; MC-190; MC-199 9040 Medicaid - AD Waiver Home Delivered Meals FA-84; MC-190; MC-199 8382 Medicaid - AD Waiver Independence Skills Management FA-84 - Agencies; FA-100 - Individuals; MC-190; MC-199 61 Medicaid - AD Waiver Non-Emergency Transportation (NET) MS-84; MC-190; MC-199 2500 Medicaid - AD Waiver Child Care for Children with Disabilities In-Home FA-84; MC-190; MC-199 Type Code (field 10a) Program Type of Provider (field 10b) 9233 Medicaid - AD Waiver Independence Skills Management In-Home FA-84; MC-190; MC-199 1113 Medicaid - AD Waiver Respite Care Income FA-84; MC-190; MC-199 5390 Medicaid - AD Waiver Nutrition Services FA-84 - Agencies; FA-100 - Individuals; MC-190, MC-199 3447 Medicaid - AD Waiver Personal Emergency Response System FA-84; MC-190; MC-199 7395 Medicaid - AD Waiver Respite Care FA-84 - Agencies; FA-100 - Individuals; MC-190; MC-199 11 Medicaid - AD/TBI Waiver Assisted Living MS-84; MC-190; MC-199 9539 Medicaid - DD Waiver Community Living & Day Support FA-84 - Agencies; FA-100 - Individuals 1398 Medicaid - DD Waiver Home Modification FA-84 - Agencies; FA-100 - Individuals 7599 Medicaid - DD Waiver Homemaker FA-84 - Agencies; FA-100 - Individuals 3447 Medicaid - DD Waiver Personal Emergency Response System FA-84 - Agencies; FA-100 - Individuals 7395 Medicaid - DD Waiver Respite FA-84 - Agencies; FA-100 - Individuals Medicaid - DD Waiver Specialized Residential Services FA-84 - Agencies; FA-100 - Individuals Medicaid - DD Waiver Specialized Day Services FA-84 - Agencies; FA-100 - Individuals 6995 Medicaid - DD Waiver Vehicle Modifications FA-84 - Agencies; FA-100 - Individuals 4479 Medicaid - DD Waiver Adult Companion Service FA-84 - Agencies; FA-100 - Individuals 2546 Medicaid - DD Waiver Adult companion Service In-Home FA-84 - Agencies; FA-100 - Individuals 6221 Medicaid - DD Waiver Adult Day Services FA-84 - Agencies; FA-100 - Individuals 7783 Medicaid - DD Waiver Consultative Assessment Service FA-84 - Agencies; FA-100 - Individuals 4428 Medicaid - DD Waiver Crisis Intervention Support FA-84 - Agencies; FA-100 - Individuals 6845 Medicaid - DD Waiver Habilitative Community Inclusion FA-84 - Agencies; FA-100 - Individuals 5416 Medicaid - DD Waiver Habilitative Workshop FA-84 - Agencies; FA-100 - Individuals 8362 Medicaid - DD Waiver Prevocational Services FA-84 - Agencies; FA-100 - Individuals 2656 Medicaid - DD Waiver Respite - Agency FA-84 - Agencies; FA-100 - Individuals 8148 Medicaid - DD Waiver Respite - Independent In-Home FA-84 - Agencies; FA-100 - Individuals 9042 Medicaid - DD Waiver Respite - Independent - Out FA-84 - Agencies; FA-100 - Individuals 9695 Medicaid - DD Waiver Supported Employment - Individual FA-84 - Agencies; FA-100 - Individuals 8264 Medicaid - DD Waiver Support Employment - Enclave FA-84 - Agencies; FA-100 - Individuals 2141 Medicaid - DD Waiver Supported Employment - Follow Along FA-84 - Agencies; FA-100 - Individuals 3764 Medicaid - DD Waiver Transportation FA-84 - Agencies; FA-100 - Individuals Type Code (field 10a) Program Type of Provider (field 10b) 7835 Medicaid - DD Waiver Transitional Services FA-84 - Agencies; FA-100 - Individuals 2633 Medicaid - DD Waiver Environmental Modification Assessment FA-84 - Agencies; FA-100 - Individuals 9769 Medicaid - DD Waiver Homemaker - Agency FA-84 - Agencies; FA-100 - Individuals 9393 Medicaid - DD Waiver Homemaker - Independent FA-84 - Agencies; FA-100 - Individuals 2611 Medicaid - DD Waiver In-Home Res Habilitation FA-84 - Agencies; FA-100 - Individuals 9844 Medicaid - DD Waiver Residential Habilitation FA-84 - Agencies; FA-100 - Individuals 3447 Medicaid - DD Waiver Emergency Response System FA-84 - Agencies; FA-100 - Individuals 9418 Medicaid - DD Waiver Assistive Technology and Supports FA-84 - Agencies; FA-100 - Individuals Medicaid- MFP Transistion Planning and Support (TPS) FA-84 - Agencies; FA-100 - Individuals entered in 11a. Primary Specialty Code (11a) Primary Specialty Description Primary Specialty Code (11a) Primary Specialty Description 01 General Practice 48 Podiatrist - Surgical Chiropodist 02 General Surgery 49 Miscellaneous-MIPS, Ambulatory Surgical Center, Etc 03 Allergy 50 Reserved 04 Otology, Laryngology, Rhinology (ENT) 51 Medical Supply Company with Certified Orthotist (CO) Certification 05 Anesthesiology 52 Medical Supply Company with Certified Prosthetist (CP) Certifica- tion 06 Cardiovascular Disease 53 Medical Supply Company with Certified Orthotist-Prosthetist (CPO) Certification 07 Dermatology 54 Medical Supply Company not included in 51, 52, or 53 08 Family Practice 55 Individual Certified Orthotist (CO) 09 Reserved 56 Individual Certified Prosthetist (CP) 10 Gastroenterology 57 Individual Certified Orthotist-Prosthetist (CPO) 11 Internal Medicine (Includes Geriatrics & Nephrology) 58 Individual not included in 55, 56, or 57 12 Internal Medicine (Restricted to group with multi spe- cialties) 59 Ambulance 13 Neurology 60 Public Health or Welfare Agencies (Federal, State & Local) 14 Neurological Surgery 61 Voluntary Health or Charitable Agencies 15 Reserved 62 Licensed Psychologist (Clinical) 16 OB/GYN 63 Portable X-ray supplier (Billing Independently) 17 Ophthamology, Otology, Laryngology, Rhinology (EENT) 64 Audiologists (Billing Independently) 18 Ophthamology 65 Physical Therapist (Billing Independently) 19 Oral Surgery (Dentist only) 66 Hospitals 20 Orthopedic Surgery 67 Urgent Cared Health Plan (OPHP) 21 Reserved 68 Dialysis 23 Peripheral Vascular Disease or Surgery 70 Clinic 24 Plastic Surgery 71 Diagnostic X-ray Clinic 25 Physical Medicine & Rehabilitation 72 Diagnostic Laboratory Clinic 26 Psychiatry/Mental Health/Substance Abuse 73 Physiotherapy 28 Proctology 74 Occupational Therapy 29 Pulmonary Disease 75 Assisted Living Services 30 Radiology - X-ray 76 Other Physician Specialist for HEALTH CHECK Follow-up 32 Radiation Therapy 77 Other Provider (non-MD) for HEALTH CHECK Follow-up 33 Thoracic Surgery 78 Screening Physician & Other Physician Specialist for HEALTH CHECK Follow-up 34 Urology 79 Adult Day Care 35 Chiropractor 80 Rehab Providers (MRO) (DPI) 36 Nuclear Medicine (MD only) 81 Rehab Acute Hospital 37 Pediatrics 82 Hospice 38 Endocrinology, Diabetes 87 All Other-Including AD Waiver 39 Gerontology 88 Unknown - Suppliers 40 Hand Surgery 89 Chemical Dependency 41 Oncology/Hematology 90 Nurse Midwife 42 Epidemiology/Infectious Disease 91 Nurse Practitioner 43 Certified Registered Nurse Anesthetist (CRNA) 94 PSC Exempt (Public Transportation) Primary Specialty Code (11a) Primary Specialty Description Primary Specialty Code (11a) Primary Specialty Description 44 Nephrology 95 Commercial NET (Licensed by the Public Service Commission) 45 Neonatology 96 Individual NET (Friend, neighbor or family member who is not legally responsible for the client or in the business of transporta- tion for hire). 46 Rheumatology 99 Unknown - Practitioners 47 Physiological Labs (Independent)
Appears in 1 contract
Sources: Nebraska Service Provider Agreement