Contents

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Home

• What's New . Read the latest news from the Nebraska Workers' Compensation Court. Request email notification of court news.
• Contents
• Public Hearings
• Requests For Proposal
• Career Opportunities
• Disclaimer
• Emergency/Disaster Information

About the Court

• Contact Information
• Judges / Professional Staff
• History, Mission, & Organization

Hearings & Decisions

• Current Calls for Hearing
• Decisions & Orders Search
• Appellate Court Decisions

Frequently Asked Questions

• Employee FAQs
• Employer FAQs
• All FAQs
• HIPAA

Insurance Coverage

• Nebraska Proof of Coverage Online Look-Up Internet Search Application
• Self Insurance Information
  • List of Court-Approved Self-Insured Employers
  • Rules 69 - 76 (PDF: 0.25 KB)

Public Information

• Record Requests
• Publications / Forms
  • Nebraska Workers' Compensation Laws and Rules Annotated (published by LexisNexis)
  • Rules of Procedure (PDF: 1.0 KB)
  • Annual Report (published by fiscal year)
  • Statistical Report (published by calendar year)
  • Occupational Surveys
  • Bulletin
  • Agricultural Operations & Workers' Compensation (PDF: 0.25 KB)
  • Rights & Obligations (PDF: 0.25 KB)
  • Rights & Obligations (Spanish) (PDF: 0.25 KB)
  • Choosing a Doctor (PDF: 0.25 KB)
  • Choosing a Doctor (Spanish) (PDF: 0.25 KB)
  • Vocational Rehabilitation Services (PDF: 0.25 KB)
  • Vocational Rehabilitation Services (Spanish) (PDF: 0.25 KB)
  • Informal Dispute Resolution & Mediation (PDF: 0.25 KB)
  • Information for Claimants Not Represented by an Attorney (PDF: 0.25 KB)
  • Fee Schedules (for Medical Services, Hospital and Ambulatory Surgical Centers, Implantable Medical Devices, and Hospital Diagnostic Related Group (DRG))
  • Order Form (PDF: 0.25 KB)
  • Record Request Form (a secure form that may be completed and filed electronically)
  • Informal Dispute Resolution Request Form (PDF: 0.25 KB)
  • Form 1: First Report of Alleged Occupational Injury or Illness (PDF: 0.25 KB). Note: Companies that have signed a Trading Partner Agreement with the Nebraska Workers' Compensation Court may use this form only with the court's permission.
  • Form 4: Subsequent Report (PDF: 0.25 KB). Note: Companies that have signed a Trading Partner Agreement with the Nebraska Workers' Compensation Court may use this form only with the court's permission.
  • Form10T: Termination of Corporate Officer Waiver (PDF: 0.25 KB)
  • Form 12: Record of Compensation Insurance (PDF: 0.25 KB)
  • Form 12P: Record of Compensation Insurance (Intergovernmental Risk Management Pool) (PDF: 0.25 KB)
  • Form 50: Choice of Doctor (PDF: 0.25 KB)
  • Form 50: Choice of Doctor (Spanish) (PDF: 0.25 KB)
  • Form 63-1: Request for Independent Medical Examiner (PDF: 0.25 KB)
  • Form 67-2: Notice of Agreement to Use a Named Independent Medical Examiner (PDF: 0.25 KB)
  • Form 62: Independent Medical Examiner Application for Appointment (PDF: 0.25 KB)
  • Vocational Rehabilitation Publications / Forms

Electronic Filings

• Lump Sum Settlement E-Filings
• EDI Information & Services
  • EDI Advisory (02/08/2007)
    • Previous EDI Advisories
    • Select this link to receive email notification of new EDI Advisories
  • Request a court-assigned value for a missing or invalid Social Security Number
  • Claims Search Database
  • Trading Partner Agreement and Exhibit 'A' (PDF: 0.25 KB) Note: This PDF document must be downloaded and completed by all new trading partners. Please return the signed original by postal mail to the Nebraska Workers' Compensation Court, P.O. Box 98908, Lincoln NE 68509-8908. (No faxes of this document will be accepted).
  • Transmission Profile — Sender's Response
  • Trading Partner Profile & Insurer ID Listing
  • EDI First Report of Injury Implementation Guide (PDF: 0.25 KB). Revised 02/08/2007
  • EDI Subsequent Report of Injury Implementation Guide (PDF: 0.25 KB). Revised 02/08/2007
  • EDI Proof of Coverage Implementation Guide (PDF: 0.25 KB). Revised 06/09/2006
  • Rule 29, First Report of Alleged Occupational Injury or Illness (PDF: 0.25 KB)
  • Rule 30, Subsequent Report (PDF: 0.25 KB)
  • Rule 32, Reporting of Compensation Insurance (PDF: 0.25 KB)
  • Record Formats & Layouts
  • IAIABC EDI Information
  • EDI Trading Partners (PDF: 0.25 KB)
  • EDI Vendors (PDF: 0.25 KB)

Legal

• Statutes & Rules
• Benefit Tables (PDF: 0.25 KB)
• Medicare Set-Aside Guidelines (PDF: 0.25 KB)
• Benefit Calculation / Software
  • Software: Present Value Calculator
  • Software: Weeks Between Dates and Benefit Calculator

Medical

• Fee Schedules
  • Flowchart: Which Fee Schedule Applies? (PDF: 0.25 KB)
  • Rule 26 (PDF: 0.25 KB)
  • Nebraska Workers' Compensation Court Fee Schedules:
    • Medical Services Fee Schedule. Effective July 1, 2006 as amended January 1, 2008. Note: Applies when payment is made on or after July 1, 2006, regardless of the date the service was provided.
    • Hospital and Ambulatory Surgical Center Fee Schedule
    • Implantable Medical Device Fee Schedule
  • Diagnostic Related Group (DRG) Inpatient Hospital Fee Schedule
• Independent Medical Examiners
  • List of Court-Appointed Independent Medical Examiners (PDF: 0.25 KB)
  • IME Information Sheet (PDF: 0.25 KB)
  • Form 63-1: Request for Independent Medical Examiner (PDF: 0.25 KB)
  • Form 67-2: Notice of Agreement to Use a Named Independent Medical Examiner (PDF: 0.25 KB)
  • Form 62: Independent Medical Examiner Application for Appointment (PDF: 0.25 KB)
  • Rules 62 - 67 (PDF: 0.25 KB)
• Managed Care Plans
  • List of Court-Certified Managed Care Plans (PDF: 0.25 KB)
  • Rules 51 - 61 (PDF: 0.25 KB)

Vocational Rehabilitation

• VR Information & Services
  • Vocational Rehabilitation FAX
  • List of Court-Certified Private Vocational Rehabilitation Counselors (PDF: 0.25 KB)
  • Ethical Standards and Responsibilities for Vocational Rehabilitation Providers (PDF: 0.25 KB)
  • NWCC Policy Statement: Plan Justification & Requests for Information (PDF: 0.25 KB).
  • Vocational Rehabilitation Meetings
    • 2008 VR Meetings
    • 2007 VR Meetings
    • 2006 VR Meetings
    • 2005 VR Meetings
    • 2004 VR Meetings
  • Cities by Vocational Rehabilitation Specialist
• VR Publications / Forms
  • Vocational Rehabilitation Services (PDF: 0.25 KB)
  • Vocational Rehabilitation Services (Spanish) (PDF: 0.25 KB)
  • Rules 36 - 45 (PDF: 0.25 KB)
  • Form VR-37E: Case Closure Report (PDF: 0.5 KB)
  • Form VR-39: Application for Certification (PDF: 0.5 KB)
  • Form VR-39A: Application for Renewal of Certification (PDF: 0.25 KB)
  • Form VR-42: VR Counselor Designation (PDF: 0.5 KB)
  • Form VR-42B: VR Counselor Appointment Request (PDF: 0.5 KB). Note: Send one copy each to the Nebraska Workers' Compensation Court, Employer/Insurer/Insurer Attorney, and Employee/Employee Attorney.
  • Form VR-42C: Agreement for the Selection of a VR Counselor (PDF: 0.25 KB)
  • Form VR-42C: Agreement for the Selection of a VR Counselor (Spanish) (PDF: 0.25 KB)
  • Form VR-43: Request for Change of VR Counselor (PDF: 0.25 KB). Note: Send one copy each to the Nebraska Workers' Compensation Court, Employer/Insurer/Insurer Attorney, Employee/Employee Attorney, and Current Vocational Rehabilitation Counselor.
  • Form VR-44: VR Plan (PDF: 0.25 KB)
  • Form VR-44S: Supplemental Billing Request (PDF: 0.25 KB)
  • Form VR-44SI: Student Information and Instructions (PDF: 0.25 KB)
  • Form VR-44JPI: Job Placement Information and Instructions (PDF: 0.25 KB)
  • Job Search Mileage Reimbursement Request:
    • Select this link to report travel on and after 01/01/2008:
      Job Search Activity Log—Mileage Reimbursement Request, effective 01/01/2008. (PDF: 0.25 KB)
    • Select this link to report travel prior to 01/01/2008:
      Job Search Activity Log—Mileage Reimbursement Request, effective 01/01/2007. (PDF: 0.25 KB)
  • Training Mileage Reimbursement Request:
    • Select this link to report travel on and after 01/01/2008:
      Training Mileage Reimbursement Request, effective 01/01/2008. (PDF: 0.25 KB)
    • Select this link to report travel prior to 01/01/2008:
      Training Mileage Reimbursement Request, effective 01/01/2007. (PDF: 0.25 KB)
  • Monthly Tutor Payment Form (PDF: 0.5 KB)
  • Instructor's Monthly Progress Report (PDF: 0.5 KB)
  • Program of Study (PDF: 1.0 KB). Note: this is a voluntary form.
  • Post-Secondary End of Term Report (PDF: 0.25 KB). Note: this is a voluntary form.

Related Links

• Workers' Comp Agencies
• Other Related Links

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