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


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


25. Electronic Remittance Advice (ERA) Authorization Agreement


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


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


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


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


30. Consent For Sterilization - Spanish - HHS 687


31. ICFIID Temporary Enhanced Rates Effective July 1, 2023


32. ICD-10 Emergency Codes Listing - October 2024


33. Request for Determination of Coverage and Pricing


34. Consent For Sterilization - English - HHS 687


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


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


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


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


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


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


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


42. EFT Application


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


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


45. ICD-10 Emergency Codes Listing - October 2023


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


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


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


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