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Provider Information and Forms

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. TPL Payments

  5. HPV Vaccine Reminder

  6. DC Nursing Facility Cost Report Instructions

  7. Conduent EDI Gateway Pharmacy Registration

  8. Compiled Behavioral Health Transformation Demonstration Program Rates

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

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

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

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

  13. Conflict-Free Case Management Self-Attestation Form

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

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

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

  17. Conduent EDI Provider Enrollment Form

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

  19. Hospice Election and Physician Certification

  20. Revised Behavioral Health Transformation Demonstration Program Rates

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

  22. 719A Prior Authorization Request Form

  23. DC Nursing Facility Cost Report Form

  24. Hospice Discharge Form

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

  26. DC Alliance Formulary List

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

  28. Change of Ownership Form

  29. EFT Application

  30. Prescription Order Form Instructions

  31. Electronic Prescription Order Form (ePOF)

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

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

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

  35. Single Case Agreement Policies and Procedures

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  53. e1346 Form

  54. Comprehensive List of Providers

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

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

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

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

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

  60. Housing Supportive Services FAQs

  61. ICD-10 Emergency Codes Listing - October 2022

  62. Consent For Sterilization - Spanish - HHS 687

  63. Consent For Sterilization - English - HHS 687