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 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)
- Certificate of Need for Psychiatric Residential Treatment Facility (PDF)
- Critical Incident Report Form (PDF)
- Disease Management Referral (PDF)
- Electroconvulsive Therapy (ECT) Form (PDF)
- Intensive Outpatient Mental Health/Chemical Dependency Form (PDF)
- Medicaid Rehab Option (MRO) Request (PDF)
- Neuro Psychological Testing OTR Form (PDF)
- Outpatient Treatment Request (OTR) General BH (PDF)
- Outpatient Treatment Request (OTR) Non-Par (PDF)
- Provider Claim Appeal Form (PDF)
- Provider Incomplete Information Fax (PDF)
- Provider Reconsideration Form (PDF)
- Wellness Plan (PDF)
Maximus Provider Enrollment Portal