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. Out-of-State Nursing Facility Placement Form


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


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


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


26. ICD-10 Emergency Codes Listing - October 2025


27. DC EAPG Never Pay List Eff 10-01-2025 DCO25002


28. DC EAPG Never Pay List Eff 01-01-2026 DCO25026


29. Electronic Remittance Advice (ERA) Authorization Agreement


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


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


32. DC Specialty Hosp FAQ Eff 10-01-2025 DCS25003


33. Consent For Sterilization - Spanish - HHS 687


34. Request for Determination of Coverage and Pricing


35. Consent For Sterilization - English - HHS 687


36. Transmittal 25-11 - DCPFS25008 2025 Professional Fee Schedule Update - Manual Pricing Codes


37. Transmittal 25-11 - DCPFS25007 2025 Professional Fee Schedule Update


38. Primary Care Self Attestation List


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


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


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


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


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


44. ICF FY 2025- Jul 1, 2025 Rates Adjusted to the LW_Final Web Upload


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


46. DC APR-DRG Pricing Calculator Eff 10-01-2025 DCI25002


47. DC Specialty Hosp DRG Pricing Calculator Eff 10-01-2025 DCS25002


48. DC APR-DRG FAQ Eff 10-01-2025 DCI25003


49. DC EAPG Information on EAPGs Eff 10-01-2025 DCO25006


50. DC EAPG Grouper Settings Eff 10-01-2025 DCO25004


51. DC EAPG Relative Weights Eff 10-01-2025 DCO25003


52. DHCF EFT Application


53. Health Care Alliance Provider FAQs


54. DC EAPG FAQ Eff 10-01-2025 DCO25005