Nebraska Total Care covers all behavioral health services that are included in the Heritage Health plan. A complete list of services, CPT codes, and authorization requirements can be found on the Pre-Auth Check page.
Attention All Outpatient Behavioral Health Providers: The provider portal enhancements are complete.
BH Providers are able to submit electronic authorization requests for the following services:
- Community Based Service
- Day Treatment
- ECT (Electroconvulsive Therapy)
- IOP (Intensive Outpatient Therapy)
- Psychological Testing
- Psychiatric Evaluation
*All other higher levels of care require prior authorizations to be submitted via fax.
All BH providers are able to see their authorizations on the provider portal.
Fax to 866-535-6974
- Certificate of Need
- Discharge summaries
- Inpatient clinical documentation
Fax to 866-593-1955
- Outpatient Treatment Requests
- Outpatient clinical documentation
Fax to 866-714-7991
- Appeals information
- Retro-authorization requests
- DHHS Provider Bulletin No. 17-05 (Initial PA Time Periods for Certain BH Services) (PDF)
- Applied Behavioral Analysis OTR Form (PDF)
- Certificate of Need for Psychiatric Residential Treatment Facility (PDF)
- DHHS Provider Bulletin No. 16-26 (Continuity of Care) (PDF)
- Disease Management Referral (PDF)
- Electroconvulsive Therapy (ECT) OTR Form (PDF)
- General BH Outpatient Treatment Request (OTR) Form (PDF)
- Intensive Outpatient/Day Treatment OTR Form - MH/SUD (PDF)
- Medicaid Rehab Option (MRO) Request (PDF)
- Psychological Testing OTR Form (PDF)
- Non-Par Outpatient Treatment Request (PDF)
- Provider Incomplete Information Fax (PDF)
- Wellness Plan (PDF)
- DHHS Provider Bulletin No. 15-54 (Provider Screening and Enrollment - Maximus Information) (PDF)
- Maximus Provider Enrollment Portal
- HPA No. 17-08 (PDF)
Medical Necessity Determinations
For Medical Necessity determinations for behavioral health services, Nebraska Total Care uses InterQual, American Society of Addition Medicine (ASAM), and Community Based Medical Necessity Criteria (MNC) based on the Nebraska Medicaid Behavioral Health Service Definitions.