Update Member Assignment Limitations

Practitioner Name

First Name *

Last Name *

Practitioner NPI # *

Tax ID # *

Group/Facility Name *

Group NPI # *

Service Location Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Practitioner Type * Primary Care Provider (PCP) Specialist

Is Practitioner Accepting New Members? * Yes No

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

Primary Care Provider (PCP) NPI # *

Primary Care Provider (PCP) Name

First Name *

Last Name *

Tax ID # *

Group/Facility Name *

Group NPI # *

Multiple Practioners

All fields are required.

If multiple practitioners' provider updates are needed, please download the Nebraska Total Care Roster Template and attach it in the upload field. All roster fields are required.

Nebraska Total Care Roster Template (Excel)
(Roster template revised 03/02/2023)

Service Location Address

Street Address *

Address Line 2

City *

State *

Zip Code *

New Panel Size *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

Primary Care Provider (PCP) NPI # *

Primary Care Provider (PCP) Name

First Name *

Last Name *

Tax ID # *

Group/Facility Name *

Group NPI # *

Multiple Practioners

All fields are required.

If multiple practitioners' provider updates are needed, please download the Nebraska Total Care Roster Template and attach it in the upload field. All roster fields are required.

Nebraska Total Care Roster Template (Excel)
(Roster template revised 03/02/2023)

Service Location Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Practitioner Type * Primary Care Provider (PCP) Specialist

New Age Restrictions *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

This form will send your message to Nebraska Total Care as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Nebraska Total Care through email, you accept associated risks. Nebraska Total Care does not accept responsibility or liability for any loss or damage arising from the use of email.

To ensure the safety of your protected health information (PHI), please send a secure email message directly to our Contract Coordinators at NetworkManagement@NebraskaTotalCare.com while providing the Group NPI in reference.

Additionally, status updates are achieved with a direct email to our Contract Coordinators at NetworkManagement@NebraskaTotalCare.com, including the Group NPI and practitioner’s NPI(s) as applicable.