Behavioral Health
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 Behavioral Health Benefits Grid.
An overview of our integrated health program can be found on the Behavior Health Provider Resource Guide.
Attention All Outpatient Behavioral Health Providers: Please be advised that the functionality for authorization submissions is currently under construction. We appreciate your feedback and are working to enhance authorization functionality. Until the enhancements are completed, please submit your requests for authorization via fax.
Fax to 866-535-6974
- Certificate of Need
- Discharge summaries
- Inpatient clinical documentation
Fax to 866-593-1955
- Outpatient Treatment Requests
- Outpatient clinical documentation
Forms and Bulletins for Behavioral Health Providers
- DHHS Provider Bulletin No. 17-05 (Initial PA Time Periods for Certain BH Services)
- Applied Behavioral Analysis OTR Form
- Certificate of Need for Psychiatric Residential Treatment Facility
- DHHS Provider Bulletin No. 16-26 (Continuity of Care)
- Disease Management Referral
- ECT OTR Form
- General BH Outpatient Treatment Request (OTR) Form
- Intensive Outpatient/Day Treatment OTR Form - MH/SUD
- MRO Request
- Psychological Testing OTR Form
- Non-Par Outpatient Treatment Request
- Provider Incomplete Information Fax
- Wellness Plan
- DHHS Provider Bulletin No. 15-54 (Provider Screening and Enrollment - Maximus Information)
- Maximus Provider Enrollment Portal
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 Service Definitions which can be accessed by visiting http://dhhs.ne.gov/medicaid/Pages/medHHBHIntegrationAdvisory.aspx