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. Revised Behavioral Health Transformation Demonstration Program Rates


11. 719A Prior Authorization Request Form


12. DC Nursing Facility Cost Report Form


13. Hospice Discharge Form


14. DC Alliance Formulary List


15. Change of Ownership Form


16. Prescription Order Form Instructions


17. Electronic Prescription Order Form (ePOF)


18. Single Case Agreement Policies and Procedures


19. Transmittal 24-21 ICFIID Medicaid Fee Schedule


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


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


22. e1346 Form


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


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


25. Electronic Remittance Advice (ERA) Authorization Agreement


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


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


28. Consent For Sterilization - Spanish - HHS 687


29. ICFIID Temporary Enhanced Rates Effective July 1, 2023


30. ICD-10 Emergency Codes Listing - October 2024


31. Request for Determination of Coverage and Pricing


32. Consent For Sterilization - English - HHS 687


33. EFT Application


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


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


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


37. ICD-10 Emergency Codes Listing - October 2023


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


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


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


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