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. ICD-10 Emergency Codes Listing - October 2025


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


29. Electronic Remittance Advice (ERA) Authorization Agreement


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


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


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


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


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


35. Consent For Sterilization - Spanish - HHS 687


36. ICFIID Temporary Enhanced Rates Effective July 1, 2023


37. Request for Determination of Coverage and Pricing


38. Consent For Sterilization - English - HHS 687


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


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


41. Primary Care Self Attestation List


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


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


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


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


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


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


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


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


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


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


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


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


54. ICD-10 Emergency Codes Listing - October 2023


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


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


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


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


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


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


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


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


63. DHCF EFT Application


64. Health Care Alliance Provider FAQs


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