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Government of the District of Columbia Department of Health Care Finance Fee-For-Service Medicaid Program 719A Prior Authorization Request.
The new 719A form incorporates the CMS requirement that a physician or nurse practitioner certify a face-to-face encounter, when ordering home care services and Durable Medical Equipment (DME).
Provider Information and Forms. Long Term Care Program Medical Assistance Application. Request For Action 1346. Conversion Change Report Form. Conversion Renewal Form. Combined Application for Food, Medical and Cash Benefits. Supplemental Form for Long Term Care Benefits.
Effective March 1, 2017, the 719A (Prior Authorization Request Form) was revised. The new 719A form incorporates the CMS requirement that a physician or nurse practitioner certify a face-to-face encounter, when
The Department of Health Care Finance (DHCF's) 719A form is used to request an authorization for medical/surgical service (s), for the Fee-for-Service (FFS) Medicaid beneficiaries. The 719A has been revised, and will be in effect starting March 1, 2017.
719A Prior Authorization Request. Justification: PATIENT HAS DIAGNOSIS OF BIPOLAR DISORDER, MENTAL RETARDATION, SEVERE PROTEIN MALNUTRITION, MALIGNANT NEOPLAMS AND REQUIRES SKILLED NURSING FOR MEDICATION MANAGEMENT FOR 1 HOUR, TWICE DAILY. THE CURRENT REQUEST IS FROM 09/01/21 TO 10/31/2021.
THE CERTIFIED DC MEDICAID DME BILLING SUPPLIERS MUST SUBMIT THE COMPLETED 719A FORM (PRIOR AUTHORIZATION FORM), PRELSCRIPTION, MEDICAL JUSTIFICATION AND CHART NOTES (IF REQUIRED) TO QUALIS (dc Medicaid) VIA QUALIS’ WEBPORTAL OR FAXED TO QUALIS (QUALIS HANDLES ALL DME PRIOR AUTHORIZATIONS FOR DC MEDICIAD-DHCF).