Nebraska NE

Last award: 2023-05-04. Next due: 2028-mid (RFP expected ~12-18 months before 2029-01-01). Contracts extended through: None.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

# NE — learned PA profile (local Qwen synthesis, 2026-05-28) Synth note: map=qwen2.5:7b / reduce=qwen2.5-coder:32b, 6 docs. See [[state_shape_NE]]. Correction pass: WISeR is not applicable to NE — WISeR ("Wasteful and Inappropriate Service Reduction") is a CMS Medicare PA model limited to AZ/NJ/OH/OK/TX/WA; NE does not participate. The model's "WISeR pilot status unspecified" line was a template artifact, corrected below. The CPT codes cited for nebulized albuterol (95485 / 92502) appear in the per-doc summaries but are implausible for that drug and should be treated as unverified. ## 1. How NE requires PA Nebraska's Medicaid program requires prior authorization (PA) for various services and treatments to ensure medical necessity and appropriate utilization. The requirements are dispersed across multiple regulatory documents and provider handbooks. For instance, nebulized albuterol for asthma treatment requires step therapy and documentation of medical necessity (specific CPT codes cited in source summaries are unverified). Prescription drugs also require PA with criteria including medical necessity and step therapy for certain drugs. Other specific services like wheelchairs, augmentative communication devices, and air fluidized beds have their own PA requirements detailed in separate documents (e.g., 471-000-208, 471-000-207, and 471-000-209 respectively). ## 2. How NE publishes and reports PA Nebraska's Medicaid program publishes PA requirements through a combination of regulatory documents hosted on the Nebraska Secretary of State's portal (rules.nebraska.gov) and provider handbooks available on the Nebraska Department of Health and Human Services (DHHS) website. The provider manuals are updated periodically, with the latest version effective January 2026. The Medicaid Provider Manual includes detailed PA criteria for prescription drugs. Specific service chapters within Title 471 NAC provide further guidance. The DHHS Division of Medicaid & Long-Term Care maintains these documents. ## 3. NE's CMS-0057-F and PA-reform compliance posture Nebraska's compliance with CMS-0057-F is not explicitly detailed in the source documents. Given the dispersed nature of Nebraska's PA requirements across multiple regulatory chapters and provider handbooks, compliance would involve compiling information from these various sources. The state's ongoing efforts to update and maintain its provider manuals and regulatory documents suggest a commitment to transparency. (WISeR not applicable — NE is not one of the six WISeR-model states.) ## 4. How NE runs its own program Nebraska's Medicaid program is managed by the DHHS Division of Medicaid & Long-Term Care. The program includes a Managed Care Organization (MCO) model, with Heritage Health serving as the current MCO. Pharmacy benefits are carved into the MCO with a uniform Preferred Drug List (PDL). Behavioral health services are carved in to the MCO, while long-term services and supports (LTSS) are carved out to state Fee-for-Service (FFS). The program also includes an 1115 waiver, the Heritage Health Adult Demonstration (NE-0003), currently active. Another 1115 waiver, the Nebraska Sustainable Coverage Demonstration, is pending approval. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Dispersed Documentation**: PA requirements are spread across Title 471 NAC chapters, provider handbooks, and specific service forms. - **Regular Updates**: Provider manuals and regulatory documents are regularly updated. - **Specific Service Requirements**: Each service has its own set of PA criteria, which can vary (e.g., step therapy for some services but not others). ### What's Missing/Uncertain: - **CMS-0057-F Compliance Details**: No specific information on how Nebraska complies. - **Gold Card Law and WISeR**: Gold card law status is unspecified; WISeR is not applicable (NE is not a WISeR-model state). - **Foster Care Program Details**: Lacking in the sources. - **Vendor Transitions**: Fiscal agents (ACS-Inc → Conduent/Gainwell) are noted; other vendor roles not detailed.

Nebraska DHHS Division of Medicaid & Long-Term Care expresses PA/coverage criteria NOT as a single PA code list but DISPERSED across (1) Title 471 NAC regulation CHAPTERS per service (hosted on the SoS portal rules.nebraska.gov), referenced from per-service "MLTC-PH-*" Provider Handbook hub pages on dhhs.ne.gov; (2) 471 NAC APPENDIX documents (471-000-NN) hosted directly on dhhs.ne.gov, which are billing instructions + Certification-of-Medical-Necessity / PA-support FORMS; (3) the master Nebraska Medicaid Provider Manual PDF (Jan 2026) which is administrative and DEFERS substantive PA criteria to the 471 NAC chapters and to each Heritage Health MCO; (4) per-MCO authorization processes for the 3 Heritage Health MCOs (Healthy Blue/Anthem, Nebraska Total Care/Centene, UnitedHealthcare). Medical necessity defined at 471 NAC 1-002.02A. Pharmacy PA is per-MCO PBM + FFS PDL. Authority = DHHS for FFS regs; MCOs for managed-care PA. Old pa_index/pharmacy/heritage_health .aspx pins all 404 (site reorg); live hubs are Provider-Handbooks / Providers / Rules-and-Regulations / Medical-Necessity. MCO manual PDFs are Akamai bot-walled.