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Add a New Provider or Term an Existing Provider

What do you want to do? required *
Product Type required * Choose all products that apply.

If multiple practitioners' provider updates are needed, please download the Nebraska Total Care Roster Template and attach it in the upload field. All roster fields are required.

Nebraska Total Care Roster New Provider Template (Excel)
(Roster template revised 03/02/2023)

Do you need to term a single PCP or multiple? required *

Primary Care Provider (PCP) Name

Practitioner will be termed from all locations associated with this TIN.
Use date format MM/DD/YYYY

If multiple practitioners' provider updates are needed, please download the Nebraska Total Care Roster Template and attach it in the upload field. All roster fields are required.

Nebraska Total Care Roster PCP Template (Excel)
(Roster template revised 08/22/2022)

Move Members To: required *

Update Requested By

Use date format MM/DD/YYYY
Do you need to term a single Specialist or multiple? required *

Specialist Name

Practitioner will be termed from all locations associated with this TIN.
Use date format MM/DD/YYYY

If multiple practitioners' provider updates are needed, please download the Nebraska Total Care Roster Template and attach it in the upload field. All roster fields are required.

Nebraska Total Care Roster Specialist Template (Excel)
(Roster template revised 08/22/2022)

Update Requested By

Use date format MM/DD/YYYY

 

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.