The 719A Form is the DC Medicaid Prior Authorization Form. Physicians and authorized prescribers use it to request pre-approval for medical services, equipment, or supplies under the District's Medicaid Fee-for-Service program and the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program for children.
To complete the 719A Form correctly, prescribers must include patient and provider details, diagnosis codes, and a written justification for the requested service. The form requires a mandatory signature from the physician or authorized prescriber. Missing information can delay processing or result in rejection by the DC Department of Health Care Finance (DHCF).
Submissions typically include supporting documents such as a Letter of Medical Necessity, a clinical evaluation or assessment, and a treatment plan. Together, these materials enable a comprehensive review that confirms treatments are medically necessary rather than experimental.
Providers filing a prior authorization request may also need a prescription drug prior authorization form or a medical management authorization form depending on the type of service requested.
| Question | Answer |
|---|---|
| Form Name | 719A Form |
| Form Length | 9 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 2 min 15 sec |
| Other names | 719a form, 719a, 719a printable, 719 form |
| Issuing Authority | DC Department of Health Care Finance (DHCF) |
| Who Can File | Physicians and authorized prescribers |
| Form Purpose | Prior authorization for medical services and supplies |