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Nebraska MS-77: Medicaid Prior Authorization Request

Nebraska Medicaid uses the MS-77 to prior authorize payment for items its regulations (471 NAC) say need approval, such as durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) and physician-administered injectable drugs. A clinician meets it when ordering one of these for a fee-for-service client. DMEPOS requests are reviewed by the Department's utilization management contractor, and injectable medication requests by the Department itself.

Who completes it

The requesting provider completes the form and signs item 17, naming the prescribing practitioner and their NPI in items 11 and 12. The Amount Authorized column, the comments box and the authorizing agent's signature are left for Medicaid staff.

Submitting and payment

How to submit it
DMEPOS requests go to the Department's utilization management contractor with documentation of medical necessity, and the contractor sends the decision. Injectable medication requests go to the Medicaid pharmacy unit by fax or email, and the Department replies directly.
Who pays
The provider enters its charge per unit in the Unit Price column, and the authorization is void if the client is ineligible or enrolled in Medicaid managed care on the date of service.

Good to know

  • Each MS-77 lists up to five services, each with a procedure code, modifier, units, unit price and a description that includes brand name and model number where relevant.
  • For rentals, item 14 asks for the purchase price, the date the item was first delivered and whether it was new or used; for purchases, enter the expected delivery date.
  • Most Nebraska Medicaid members are in Heritage Health managed care plans, which run their own prior authorization forms, so confirm the client is fee-for-service first.
  • Some drugs, including Spinraza and Leqembi, have their own drug-specific Nebraska Medicaid prior authorization forms.

Get the official form

Download the current version from the source each time; forms change without notice.

Request for Prior Authorization

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

When is a Nebraska MS-77 authorization void?

The form states the authorization is void if the client is ineligible for Nebraska Medicaid or is enrolled in the Medicaid managed care program when the service is provided. The provider is responsible for verifying eligibility, and Heritage Health plan members go through their plan's own prior authorization process instead.

Who reviews an MS-77 request?

It depends on the item. Durable medical equipment, prosthetics, orthotics and supplies are reviewed by the Department's utilization management contractor, which notifies the provider of the decision. Requests for injectable medications are reviewed by the Nebraska Department of Health and Human Services, which sends its own notification.

What happens if the MS-77 is incomplete?

The instructions say incomplete forms will be returned. Every line needs a procedure code, units and unit price, and the form must show the client's 11-digit Medicaid number, the prescribing practitioner's name and NPI, a diagnosis, and the requesting provider's signature and date.