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. CMS Approves DHCF 1915c HCBS Waiver Appendix K Emergency Preparedness Response Plan


5. DC Medicaid Coding for Telemedicine and Coronavirus (COVID-19)


6. ICD-10-CM Official Coding Guidelines Coding encounters related to COVID-19 Coronavirus Outbreak


7. TPL Payments


8. HPV Vaccine Reminder


9. DC Nursing Facility Cost Report Instructions


10. Conduent EDI Gateway Pharmacy Registration


11. Compiled Behavioral Health Transformation Demonstration Program Rates


12. Consent For Sterilization - English - HHS 687


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


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


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


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


17. Conflict-Free Case Management Self-Attestation Form


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


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


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


21. Conduent EDI Provider Enrollment Form


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


23. Hospice Election and Physician Certification


24. Revised Behavioral Health Transformation Demonstration Program Rates


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


26. 719A Prior Authorization Request Form


27. DC Nursing Facility Cost Report Form


28. Consent For Sterilization - Spanish - HHS 687-1


29. Hospice Discharge Form


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


31. DC Alliance Formulary List


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


33. Change of Ownership Form


34. EFT Application


35. Prescription Order Form Instructions


36. Electronic Prescription Order Form (ePOF)


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


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


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


40. Single Case Agreement Policies and Procedures


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


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


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


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


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


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


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


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


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


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


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


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


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


54. ICD-10 Emergency Codes Listing - October 2022


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


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


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


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


59. e1346 Form


60. Comprehensive List of Providers


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


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


63. Housing Supportive Services Tip Sheet Provider Enrollment Billing (FINAL)


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


65. Housing Supportive Services FAQs


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


67. ASC Fee Schedule