Make a Change to an IRS Number or NPI Number

Group/Facility Name *

Old Tax Identification Number (TIN) *

Old Group NPI # *

New Tax Identification Number (TIN) *

New Group NPI # *

Effective Date *

Please attach a completed IRS W-9 Form *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

Group/Facility Name *

Old Group NPI # *

New Group NPI # *

Tax ID # *

Has this NPI been updated with Nebraska Medicaid? * Yes No

Please Provide New Medicaid ID *

Please contact Maximus. The Maximus web portal can be found at: nebraskamedicaidproviderenrollment.com

Maximus Customer Service can be reached toll free at: 1-844-374-5022 or nebraskamedicaidPSE@maximus.com

Effective Date *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

This form will send your message to Nebraska Total Care as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Nebraska Total Care through email, you accept associated risks. Nebraska Total Care does not accept responsibility or liability for any loss or damage arising from the use of email.

To ensure the safety of your protected health information (PHI), please send a secure email message directly to our Contract Coordinators at NetworkManagement@NebraskaTotalCare.com while providing the Group NPI in reference.

Additionally, status updates are achieved with a direct email to our Contract Coordinators at NetworkManagement@NebraskaTotalCare.com, including the Group NPI and practitioner’s NPI(s) as applicable.