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Provider Information and Forms

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. Electronic Remittance Advice (ERA) Authorization Agreement

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

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

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

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

  32. Consent For Sterilization - Spanish - HHS 687

  33. ICFIID Temporary Enhanced Rates Effective July 1, 2023

  34. ICD-10 Emergency Codes Listing - October 2024

  35. Request for Determination of Coverage and Pricing

  36. Consent For Sterilization - English - HHS 687

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

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

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

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

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

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

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

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

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

  46. EFT Application

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

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

  49. ICD-10 Emergency Codes Listing - October 2023

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

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

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

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