The District of Columbia's Department of Health Care Finance uses Form 719A for prior authorization in its fee-for-service Medicaid program. One page covers surgery, DME, medical, pharmacy, dental, eyewear, hospice, home health and private duty nursing requests, with diagnosis and procedure codes, units and justification. It applies only to fee-for-service members, since most DC Medicaid enrollees belong to managed care organizations.
The requesting provider completes the patient, prescribing provider and servicing provider blocks, the requested services and justification, then signs the certification that the services are medically necessary. For DME, home health and private duty nursing, the requesting physician also certifies the date of a face-to-face encounter.
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719A Prior Authorization Request
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No. The 719A belongs to the District's fee-for-service Medicaid program. Most DC Medicaid members are enrolled in managed care organizations, so confirm the patient's coverage first; a managed care member's prior authorization goes through that plan rather than through this DHCF form.
The DME and home health certification lists a primary physician, nurse practitioner, certified nurse midwife, physician assistant, or acute or post-acute physician. The requesting physician records the encounter date and the prescriber's name and title, certifying that the encounter related to the primary reason the patient needs the DME or home health services.
That the requested services are medically indicated and necessary for the patient's health, and that the information on the form is true, accurate and complete. The signature block also asks for the provider's title and the date of signing.