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Revision: HCFA-PM-95-3 May 1995 (MB) ATTACHMENT 4.17 A Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska LIENS AND ADJUSTMENTS OR RECOVERIES 1. The State uses
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hcfa-pm-95-3 - dhhs ne is a form used for reporting healthcare services provided and billing information.
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Information such as patient name, date of birth, insurance information, service provided, and billing codes must be reported on hcfa-pm-95-3 - dhhs ne.
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