Provider Information and Forms

1. TPL Payments


2. HPV Vaccine Reminder


3. DC Nursing Facility Cost Report Instructions


4. Conduent EDI Gateway Pharmacy Registration


5. Compiled Behavioral Health Transformation Demonstration Program Rates


6. DC Medicaid Beneficiary Disclosure and Commitment to Take Hepatitis C Medications


7. Conduent EDI Provider Enrollment Form


8. Provider Conduent EDI Gateway Authorization Form for Billing Agents and Clearinghouses


9. Hospice Election and Physician Certification


10. 719A Prior Authorization Request Form


11. DC Nursing Facility Cost Report Form


12. Hospice Discharge Form


13. DC Alliance Formulary List


14. Change of Ownership Form


15. Prescription Order Form Instructions


16. Electronic Prescription Order Form (ePOF)


17. Single Case Agreement Policies and Procedures


18. Transmittal 24-21 ICFIID Medicaid Fee Schedule


19. Retro Eligibility Attestation Form for Long Term Care Services and Supports


20. Billing and Prior Authorization (PA) Technical Assistance Guidance


21. e1346 Form


22. DC EAPG Never Pay List Eff 01-01-2023 DCO23001


23. Out-of-State Nursing Facility Placement Form


24. Referral Form for DME Medical Assistive Devices and Services (DME MADS)


25. DC EAPG FAQ Eff 10-01-2024 DCO24006


26. DC EAPG Never Pay List Eff 01-01-2025 DCO24029


27. Electronic Remittance Advice (ERA) Authorization Agreement


28. DC APR-DRG FAQ Eff 10-01-2023 DCI23004


29. DC APR-DRG FAQ Eff 10-01-2024 DCI24004


30. DC APR-DRG Pricing Calculator Eff 10-01-2024 DCI24003


31. DC APR-DRG Pricing Calculator Eff 10-01-2023 DCI23003


32. Consent For Sterilization - Spanish - HHS 687


33. ICFIID Temporary Enhanced Rates Effective July 1, 2023


34. ICD-10 Emergency Codes Listing - October 2024


35. Request for Determination of Coverage and Pricing


36. Consent For Sterilization - English - HHS 687


37. DC EAPG Grouper Settings Eff 10-01-2024 DCO24005


38. DC Specialty Hosp FAQ Eff 10-01-2024 DCS24002


39. DC EAPG Relative Weights Eff 10-01-2023 DCO23005


40. DC EAPG FAQ Eff 10-01-2023 DCO23007


41. DC EAPG Never Pay List Eff 10-01-2023 DCO23004


42. DC EAPG Information on EAPGs Eff 10-01-2024 DCO24007


43. DC Specialty Hosp DRG Pricing Calculator Eff 10-01-2024 DCS24001


44. EFT Application


45. DC EAPG Never Pay List Eff 10-01-2024 DCO24003


46. DC EAPG Relative Weights Eff 10-01-2024 DCO24004


47. ICD-10 Emergency Codes Listing - October 2023


48. DC EAPG Grouper Settings Eff 10-01-2023 DCO23006


49. DC EAPG Information on EAPGs Eff 10-01-2023 DCO23008


50. DC Specialty Hosp FAQ Eff 10-01-2023 DCS23005


51. DC Specialty Hosp DRG Pricing Calculator Eff 10-01-2023 DCS23004