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Medicaid Update: Transmittal 17-06 - Revised 719A Form

Friday, February 24, 2017

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. 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). Moving forward, all sections of the 719A form must be completed in its entirety, hence the removal of specific numbered sections as specified in preceding transmittals.