The Nebraska Department of Insurance created this standard request under LB 77 (2025) for prior authorization of health care services, including medical injectables. From January 1, 2026, insurers and providers must accept it whenever a fully insured plan requires approval of a service. The requesting provider sends it to the insurance carrier, which applies its own clinical criteria to the request.
The requesting provider or facility completes Sections II through VI, including the service provider, service facility and the patient's primary care provider if the plan requires one. Section I, the carrier's submission details, may be prefilled on the carrier's posted copy.
Download the current version from the source each time; forms change without notice.
Nebraska Standard Prior Authorization Request Form for Health Care Services
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.
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Yes. Its instruction page is titled for health care services including medical injectables, so drugs given and billed by the provider go on this form. Drugs dispensed by a pharmacy, and durable medical equipment, belong on the companion Nebraska standard form for drug benefits or DME, which excludes provider-administered medication billed by the provider.
All fully insured health plans in Nebraska, starting January 1, 2026. The Department of Insurance says self-insured and ERISA plans are not affected, and providers can confirm a patient's plan type through insurer portals, by contacting the insurer or through automated verification systems.