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 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 Numbers
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
Behavioral Health Forms
- Applied Behavioral Analysis (ABA) Form (PDF)
- ABA Behavior Assessment and Plans Tip Sheet (PDF)
- ABA Caregiver Training Tip Sheet (PDF)
- ABA Coordination of Care Tip Sheet (PDF)
- ABA Medication Management Tip Sheet (PDF)
- ABA Outpatient Treatment Request (OTR) Tip Sheet (PDF)
- ABA Prescription Fulfillment Tip Sheet (PDF)
- ABA Transition Planning Tip Sheet (PDF)
- Behavioral Health Bulletins
- Certificate of Need for Psychiatric Residential Treatment Facility (PDF)
- Critical Incident Report Form (PDF)
- Disease Management Referral (PDF)
- Electroconvulsive Therapy (ECT) Form (PDF)
- Inpatient Medicaid Prior Authorization (PDF) (01/30/2024)
- Intensive Outpatient Mental Health/Chemical Dependency Form (PDF)
- Medicaid Rehab Option (MRO) Request (PDF)
- Neuro Psychological Testing OTR Form (PDF)
- Outpatient Medicaid Prior Authorization (PDF) (01/01/2025)
- Outpatient Treatment Request (OTR) General BH (PDF)
- Outpatient Treatment Request (OTR) Non-Par (PDF)
- Outpatient Treatment Request (OTR) Tip Sheet (PDF)
- Provider Claim Appeal Form (PDF)
- Provider Incomplete Information Fax (PDF)
- Provider Reconsideration Form (PDF)
- Wellness Plan (PDF)
Maximus Provider Enrollment Portal
Partnerships in Care (PiC)
Our Partnerships in Care (PiC) program uses data analytics and clinical reviews to enhance our partnership with you as the provider to maximize treatment successes. This approach is based on our philosophy that quality member care is achieved through purposeful collaboration with providers that serve our members receiving a multitude of behavioral health services.
If you are identified as a provider that could benefit from participation in the Partnerships in Care (PiC) program through a data analysis, we will review members’ clinical documentation then collaborate with you to highlight areas of strengths and opportunities.