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News & Announcements

Clinical Criteria updates
September 2018 Medical Policies and Clinical Utilization Management Guidelines Update
Medical necessity review for appropriate level of care
Quarterly pharmacy formulary change notice effective February 1, 2019
July 2018 Medical Policies and Clinical Utilization Management Guidelines Update
Physical and occupational therapy reviews
Reminder:State Medicaid Program Enrollment Requirement
Cultural competency and patient engagement
Long-Acting Reversible Contraceptive Update
Electronic data interchange gateway update
Prior authorization requirements for Sublocade
Prior authorization requirements for Subcutaneous Implantable Defibrillator system
Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants
Prenatal formulary change notice effective August 1, 2018
Out of State Medicaid Enrollment Exceptions
The Importance of Flouride Varnish
Medical Necessity Criteria Changes
Cervical length measurement by transvaginal ultrasound
Availity Claim Payment Disputes Training Webinar
State Medicaid Program Enrollment Requirement - All Providers
Quarterly pharmacy formulary change notice effective October 1, 2018
Prior authorization requirements for Interferon beta-1a
Prior authorization requirements for Somatrem
May 2018 Medical Policies and Clinical Utilization Management Guidelines Update
Medical Policies and Clinical Utilization Management Guidelines update - March 2018
Medical Policies and Clinical Utilization Management Guidelines update - January 2018
Quarterly pharmacy formulary change notice effective August 1, 2018
Amerigroup District of Columbia, Inc. adopts 22nd edition of the MCG care guidelines
Prior authorization requirements for Cabazitaxel
Prior authorization requirements for injectable/infusible drugs: mepolizumab (Nucala) and reslizumab (Cinqair)
Zepatier, cough and cold pharmacy formulary change notice effective June 1, 2018
Chimeric antigen receptor T-cell therapy requires prior authorization for all places of service
Services requiring prior authorization
ICS pharmacy formulary change notice update: effective April 15
Lower extremity vascular intervention codes require prior authorization
Prior authorization requirements for Darzalex drug
Electrical stimulation device to require prior authorization
Quarterly pharmacy formulary change notice effective May 1, 2018
Prior authorization requirement update for Mylotarg
Q4 Medical Policies and Clinical Utilization Management Guidelines Updates
Meningococcal vaccine update
ICS Pharmacy Formulary Change Notice
Medical Policy update - Hyaluronan Injections
2018 Utilization Management Affirmative Statement
Eight injectable drugs will require prior authorization
AIM Musculoskeletal Guidelines
Elotuzumab to require prior authorization
Welcome to the provider network family
Levoleucovorin calcium, elosulfase alfa, histrelin acetate, idursulfase and fulvestrant to require prior authorization
New Pharmacy Electronic Prior Authorization Request Tool Effective April 1, 2018
Age limits pharmacy formulary change notice effective February 1, 2018
Quarterly pharmacy formulary change notice effective February 1, 2018
Effective January 1, 2018, providers will be required to use ProView for credentialing
Alliance Behavioral Heath Inpatient and Outpatient Benefits
New review process for not otherwise classified drug codes
McKesson criteria disclosure
DHCF Open House Flier
Provider Orientation Invitation
UPDATE No/Late Notification Process
Transplant Service Request Instructions
February 2017 UPDATE to Medical Policies and Clinical Utilization Management Guidelines
Genetic Testing Services
UPDATE to Medical Policies and Clinical Utilization Management Guidelines
Prior Authorization Update for Custom Shower Chairs

Provider Self-Service

Do more online through Provider Self-Service!

  • File and check the status of medical claims
  • NEW — Submit Claims Payment Disputes electronically via Availity
  • Verify eligibility
  • Request precertification via the Interactive Care Reviewer (ICR)
  • Conduct an inquiry on the status of any precertification request via ICR
  • For more information on ICR such as features, support or training go to
    ICR-Help
  • Submit a Pharmacy Prior Authorization Request
  • And much more!

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Provider Resources & Documents
expand Behavioral Health
Concurrent Review Form
Discharge Form
Mental Health Outpatient Treatment Report Form
PRTF Treatment Review Form
expand Claims Submission and Reimbursement Policy
Electronic Data Interchange (EDI)
expand Clinical Practice Guidelines
Physical and occupational therapy reviews
expand Disease Management
Contacting Disease Management
Disease Management Referral Form
expand EPSDT
Health Check Periodicity
expand Forms
PCP Change Form - English Version
Practice Profile Update Form
CMS-1500 Form
expand ICD-10
expand Manuals & QRCs
Medicaid Quick Reference Card
expand Maternal Child Program
Prenatal Ultrasound Policy
Zika Virus FAQ
Taking Care of Baby and Me Flier
17P Provider Information Flier
Prior Preterm Pregnancy Program
expand Medical Management Model
Health Education and Wellness
expand Newsletters - Current
Inaugural Issue - Provider Newsletter
February 2018 Provider Newsletter
June 2018 Provider Newsletter
October 2018 Provider Newsletter
February 2019 Provider Newsletter
expand Pharmacy
Synagis Prior Authorization Form
Medicaid Preferred PDL
State Hepatitis C Policy: Epclusa
State Hepatitis C Policy: Mavyret
State Hepatitis C Policy: Sovaldi
State Hepatitis C Policy: Viekira
State Hepatitis C Policy: Zepatier
expand Provider Training
Provider Orientation
Cultural Competency Training
expand Quality Management
HEDIS Desktop Reference Guide for Medicaid Providers
expand Quick Tools
Medical Policies
expand Referral Directories
District of Columbia Medicaid Referral Directory
expand Training Programs
expand Vendor/Partner Links & Information
DentaQuest
AIM (Diagnostic and Imaging Service Authorizations)
CoverMyMeds ePA Request Tool
District of Columbia