Provider Information and Forms

1. DC APR-DRG FAQ Eff 10/1/2020 DCI20030


2. DC APR-DRG Pricing Calculator Eff 10/1/2020 DCI20031


3. DC EAPG Never Pay List Eff 10/1/2020 DCO20035


4. TPL Payments


5. HPV Vaccine Reminder


6. DC Nursing Facility Cost Report Instructions


7. Conduent EDI Gateway Pharmacy Registration


8. Compiled Behavioral Health Transformation Demonstration Program Rates


9. DC Specialty Hosp FAQ Eff 10/1/2020 DCS20016


10. DC EAPG Information on EAPGs Eff 10/1/2020 DCO20029


11. DC Specialty Hosp DRG Pricing Calculator Eff 10-1-2020 DCS20015


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


13. Conflict-Free Case Management Self-Attestation Form


14. DC EAPG Grouper Settings Eff 10/1/2020 DCO20031


15. DC EAPG Relative Weights Eff 10/1/2020 DCO20032


16. DC EAPG IP Only List Eff 10/1/2020 DCO20033


17. Conduent EDI Provider Enrollment Form


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


19. Hospice Election and Physician Certification


20. Revised Behavioral Health Transformation Demonstration Program Rates


21. DC EAPG FAQ Eff 10/1/2020 DCO20028


22. 719A Prior Authorization Request Form


23. DC Nursing Facility Cost Report Form


24. Hospice Discharge Form


25. Level 1 Pre-Admission Screen/Resident Review (PASRR) for SMI, ID, or Related Conditions


26. DC Alliance Formulary List


27. DC EAPG Never Pay List Eff 01-01-2022 DCO22002


28. Change of Ownership Form


29. EFT Application


30. Prescription Order Form Instructions


31. Electronic Prescription Order Form (ePOF)


32. DC EAPG Information on EAPGs Eff 10-01-2021 DCO21023


33. DC EAPG Never Pay List Eff 01/01/2021 DCO21001


34. DC EAPG FAQ Eff 10-01-2021 DCO21018


35. Single Case Agreement Policies and Procedures


36. DC APR-DRG FAQ Eff 10-01-2021 DCI21018


37. DC APR-DRG Pricing Calculator Eff 10-01-2021 DCI21019


38. DC EAPG Never Pay List Eff 10-01-2021 DCO21020


39. DC EAPG Grouper Settings Eff 10-01-2021 DCO21021


40. DC EAPG Relative Weights Eff 10-01-2021 DCO21022


41. DC EAPG IP Only List Eff 10-01-2021 DCO21019


42. DC Specialty Hosp FAQ Eff 10-01-2021 DCS21008


43. DC Specialty Hosp DRG Pricing Calculator Eff 10-01-2021 DCS21007


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


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


46. IDD Waiver Billing Technical Assistance Report (BTAR) Training


47. DC EAPG Grouper Settings Eff 10-01-2022 DCO22017


48. DC EAPG Information on EAPGs Eff 10-01-2022 DCO22019


49. DC APR-DRG FAQ Eff 10-01-2022 DCI22013


50. DC APR-DRG Pricing Calculator Eff 10-01-2022 DCI22012


51. DC EAPG Relative Weights Eff 10-01-2022 DCO22016


52. DC EAPG FAQ Eff 10-01-2022 DCO22018


53. e1346 Form


54. Comprehensive List of Providers


55. DC Specialty Hosp DRG Pricing Calculator Eff 10-01-2022 DCS22006


56. DC EAPG Never Pay List Eff 10-01-2022 DCO22015


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


58. Housing Supportive Services Benefit Tip Sheet - Provider Enrollment & Billing


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


60. Housing Supportive Services FAQs


61. ICD-10 Emergency Codes Listing - October 2022


62. Consent For Sterilization - Spanish - HHS 687


63. Consent For Sterilization - English - HHS 687