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Nebraska Medicaid Utilization Review PA Fax Form

Nebraska Medicaid's utilization management contractor uses this form for fee-for-service prior authorization and utilization review of inpatient admissions, outpatient procedures, transplants, skilled nursing transfers and DME. A clinician or facility meets it when a planned admission or service needs review. The contractor reviews the clinical documentation and faxes back an approval, or faxes and mails a denial letter.

Who completes it

The requesting provider or facility completes every section, including both NPIs and tax IDs, and a provider or representative signs an attestation that an order was received and the treatment plan was approved by the ordering physician. The servicing provider's details can be marked SAME when it is the requester.

Submitting and payment

How to submit it
Fax the form with clinical documentation to the contractor, or enter the request in the contractor's provider portal, which DHHS lists alongside phone and email contacts on its Utilization Management page.
Who pays
The form states that a certification decision does not guarantee payment; eligibility and payment remain subject to the terms and limits of the member's coverage.

Good to know

  • The 2020 form still names eQHealth Solutions; DHHS says that contractor merged into Acentra Health, with the same provider portal and authorization process.
  • Severity is Standard, Urgent or Emergent. Emergent, or head in bed, means a direct admission where the member is already in the hospital when the request is made.
  • Review type boxes cover initial, concurrent, retrospective and future admits, plus same-day IPR or SNF transfers, inpatient, outpatient and transplant requests.
  • Continuous glucose monitors have a separate CGM Medicaid prior authorization form listed on the same DHHS page.

Get the official form

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

Prior Authorization Request Form

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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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

What clinical documentation goes with the Nebraska Medicaid PA fax form?

The form asks for signs, symptoms, history, diagnostic test results, consultant recommendations if any, and the plan of treatment. It warns that requests cannot be processed without this documentation, so attach it to the fax or upload it through the portal along with the main ICD-10 code and CPT codes.

Where does the decision get sent?

To the contact person named at the top of the form. An approval is faxed back to that contact's number. A denial letter is faxed to the same number and mailed to the requesting physician, which is why the requesting and servicing provider addresses are required fields.