Transfer Request Forms and Defective PA Forms
- Memo for Beneficiary Transfer Requests 09282016.pdf
- LTCA PA Request Notification 09282016.docx
- LTCA Defective PA Form (02032016) 07142016 Savable_final.pdf
- LTCA EPDW Transfer Form (02032016) 07142016 Savable_final.pdf
- LTCA State Plan Transfer Form (02032016) 07142016 Savable_Final.pdf
Form 719A Prior Authorization Request
Nursing Facility Forms
Long Term Care Program Medical Assistance Application
- Eligibility Determination and Enrollment Process for EPD Waiver: Response to G.W. Health Insurance Counseling Project (HICP) Fact Sheet (PDF)
- District of Columbia Long-Term Care/Waiver Medicaid Application (2018)
- Retroactive Medicaid Application for Institutional Care (2018)
- Resource FAQ Sheet .pdf
- EPD FACT Sheet.pdf
- Financial Eligibility Institutional Care Fact Sheet.pdf
- Spend down FAQ Fact Sheet.pdf
POF: Prescription Order Form
RN Attestation Forms for Annual PCA Level of Need Re-certifications
Person-Centered Individual Service Plan (PCP) Guide
EAPG Documentation
- DC EAPG Relative Weights Eff 10-1-18 DCO18023.pdf
- DC EAPG Relative Weights Eff 10-01-2017 DCO17045.pdf
- DCO16035 EAPG FY17 Weights Version 3 11 2016-08-25.pdf
- DC OP Hosp EAPG Relative Weights v3 8 for DHCF 2014-09-12 S253.pdf
- DC OP Hosp EAPG Relative Weights v3 8 2015-10-01 DCs15064.pdf
EAPG Grouper Settings
- DC EAPG Grouper Settings Eff 10-1-18 DCO18022.pdf
- DC EAPG Grouper Settings Eff 10-01-2017 DCO17056.pdf
- DCO16034 EAPG Grouper Settings FY17 2016-08-25.pdf
- DC OP Hosp EAPG Grouper Settings 2015-10-01 DCs15065.pdf
- DC OP Hosp EAPG Grouper Settings for DHCF web 2014-09-12 S254.pdf
EAPG Inpatient Only List
- DC EAPG IP Only List Eff 10-1-18 DCO18024.pdf
- DC EAPG IP Only List Eff 10-01-2017 DCO17042.pdf
- DCO16029 EAPG FY17 IP Only List 2016-07-29.pdf
- DC OP Hosp EAPG IP Only List 2015-10-01 DCs15061.pdf
- DC OP Hosp EAPG IP Only List for DHCF web 2015-01-01.pdf
- DC OP Hosp EAPG IP Only List for DHCF web 2014-10-09 S263.pdf
EAPG Never Pay List
- DC EAPG Never Pay List Eff 10-1-18 DCO18021.pdf
- DC EAPG Never Pay List Eff 01-01-2018 DCO17059.pdf
- DC EAPG Never Pay List Eff 10-01-2017 DCO17043 .pdf
- DCO16024 EAPG Never Pay List FY17 2016-07-29.pdf
- DC OP Hosp EAPG Never Pay List 2015-10-1 DCs15062.pdf
- DC OP Hosp EAPG Never Pay List for DHCF web 2015-01-01.pdf
- DC OP Hosp EAPG Never Pay List for DHCF web 2014-10-09 S264.pdf
Training presentations
- DC APR-DRG Provider Training 2014-09-12 S185.pdf
- DC Spec Hosp Provider Per Stay Presentation 2014-08-14 S186.pdf
- DC Spec Hosp Provider Per Diem Presentation 2014-08-14 S185.pdf
- DC OP Hosp EAPG Provider Training 2014-09-16 S250.pdf
APR-DRG Calculator
- DC APR-DRG Pricing Calculator Eff 10-1-2018 DCI18018.xlsx
- DC APR-DRG Pricing Calculator Eff 10-01-2017 DCI17036.xlsx
- DCI16024 DC APR-DRG FY17 Calculator.xlsx
- DC APR-DRG FY15 Pricing Calculator for hospitals 2014-10-01 Revised DCs15074.xlsx
- DC APR-DRG FY16 Pricing Calculator for hospitals 2015-10-01 DCs15076.xlsx
- DC APR-DRG Pricing Calculator for hospitals 2014-08-29 S181.xls
APR-DRG Calculator Instructions
Specialty Calculator
- DC Specialty Hosp DRG Pricing Calculator Eff 10-1-18 DCS18028.xlsx
- DC Specialty Hosp DRG Pricing Calculator Eff 10-01-2017 DCS17023.xlsx
- DCS16033 FY17 Specialty Hospital DRG Calculator 2016-08-22.xlsx
- DC FY16 Specialty Hospital Per Stay Calculator 2015-10-01 DCs15081.xls
- DC Spec Hosp Per Stay Calculator Protected 2014-09-02 S203.xls
Specialty Calculator Instructions
- DC Specialty Hosp DRG Calculator Instructions Eff 10-01-2017 DCS17024.pdf
- DCS16034 FY17 Specialty Hospital Calculator Instruc 2016-08-22.pdf
- DC Spec Hosp Per Stay Calculator Instructions 2014-08-25 S195.pdf
Frequently Asked Questions
- DC Specialty Hosp FAQ Eff 10-1-18 DCS18006.pdf
- DC APR-DRG FAQ Eff 10-1-18 DCI18004.pdf
- DC EAPG FAQ 10-1-18 DCO18005.pdf
- DC Specialty Hosp FAQ Eff 10-01-2017 DCS17013.pdf
- DC EAPG FAQ Eff 10-01-2017 DCO17027.pdf
- DC APR-DRG FAQ Eff 10-1-2017 DCI17006.pdf
- DCS16032 FY17 Specialty Hospital FAQ 2016-08-22.pdf
- DCO16032 EAPG FAQ 2016-08-24.pdf
- DCI16017 APR-DRG FY17 FAQ.pdf
- DCs 16005 Spec Hosp Short-Term Inpatient FAQ 2016-04-05.pdf
- DC Specialty Hospital FAQ 2015-10-01 DCs15082.pdf
- DC APR-DRG FAQ 2015-10-01 DCs15092.pdf
- DC Outpatient Hospital EAPG FAQ 2015-10-01 DCs15090.pdf
- DC APR-DRG FAQ 2014-09-22 S197.pdf
- DC Spec Hosp FAQ 2014-09-22 S210.pdf
- DC Outpat Hosp FAQ 2014-09-22 S262.pdf
Info on EAPGs