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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. Conflict-Free Case Management Self-Attestation Form

  8. Conduent EDI Provider Enrollment Form

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

  10. Hospice Election and Physician Certification

  11. Revised Behavioral Health Transformation Demonstration Program Rates

  12. 719A Prior Authorization Request Form

  13. DC Nursing Facility Cost Report Form

  14. Hospice Discharge Form

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

  16. DC Alliance Formulary List

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

  18. Change of Ownership Form

  19. Prescription Order Form Instructions

  20. Electronic Prescription Order Form (ePOF)

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

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

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

  24. Single Case Agreement Policies and Procedures

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  42. e1346 Form

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

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

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

  46. EFT Application

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

  48. Housing Supportive Services FAQs

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

  50. Electronic Remittance Advice (ERA) Authorization Agreement

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

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

  53. Consent For Sterilization - Spanish - HHS 687

  54. ICFIID Temporary Enhanced Rates Effective July 1, 2023

  55. Request for Determination of Coverage and Pricing

  56. Consent For Sterilization - English - HHS 687

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

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

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

  60. ICD-10 Emergency Codes Listing - October 2023

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

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

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

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