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. Conflict-Free Case Management Self-Attestation Form


8. Conduent EDI Provider Enrollment Form


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


10. Hospice Election and Physician Certification


11. Revised Behavioral Health Transformation Demonstration Program Rates


12. 719A Prior Authorization Request Form


13. DC Nursing Facility Cost Report Form


14. Hospice Discharge Form


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


16. DC Alliance Formulary List


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


18. Change of Ownership Form


19. Prescription Order Form Instructions


20. Electronic Prescription Order Form (ePOF)


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


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


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


24. Single Case Agreement Policies and Procedures


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


42. e1346 Form


43. Comprehensive List of Providers


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


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


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


47. EFT Application


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


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


50. Housing Supportive Services FAQs


51. Electronic Remittance Advice (ERA) Authorization Agreement


52. ICD-10 Emergency Codes Listing - October 2022


53. Consent For Sterilization - Spanish - HHS 687


54. ICFIID Temporary Enhanced Rates Effective July 1, 2023


55. Request for Determination of Coverage and Pricing


56. Consent For Sterilization - English - HHS 687