How to Fill Out and Submit DC DHCF Form 719A: Prior Authorization

DHCF Form 719A is the District of Columbia’s prior authorization request form, used by enrolled Medicaid and DC Healthcare Alliance providers to get approval before delivering certain services. To complete it correctly, you fill in patient and provider identifiers at the top, check one service category, enter diagnosis and procedure codes with a specific clinical description, complete the face-to-face certification when required, sign and date it (with requested service dates falling within six months of your signature), and submit it with supporting medical records through the channel that matches the service and the patient’s coverage.¹

When You Need to Use Form 719A

The form covers the service categories DHCF has flagged for advance approval: surgery, durable medical equipment, home health, medical services, pharmacy, ICF/MR, dental, eyewear, nursing home, hospice, hospital, and office-based services. Certain DME always requires prior authorization, including TENS units, rollabout chairs, cervical traction devices, oxygen and respiratory equipment, hospital beds and accessories, and any DME item on the DMEPOS Fee Schedule priced at $1,000 or more.¹

Two boundaries matter before you start. First, as of May 4, 2026, prior authorization for acute care hospital services tied to surgical procedures, transplants, medical procedures, and testing runs through the Comagine Health Provider Portal rather than Form 719A.² Second, if the patient is enrolled in a Medicaid managed care organization, the MCO usually has its own form and process; Form 719A is used primarily for fee-for-service Medicaid and the DC Healthcare Alliance. Confirm the pathway with the patient’s plan before you send anything.

What to Gather Before You Start

The form is short, but every field is a potential rejection point. Have this in hand before you open it:

Beneficiary’s full name, DCID number (the District’s Medicaid ID), date of birth, sex, address, phone number, and any other health insurance coverage.
Prescribing provider’s name, address, phone, and 10-digit National Provider Identifier issued by CMS.³
Servicing provider’s name, Medicaid provider number, address, phone, and NPI, if different from the prescriber.
ICD diagnosis codes and CPT or HCPCS procedure codes for the requested service.
Time required, frequency or units, estimated charges, and a written description of what you’re requesting.

Filling In Each Section

Patient and Provider Information

Enter the DCID number exactly as it appears on the beneficiary’s Medicaid card. Transposed digits are a common reason requests come back. Prescribing provider goes on the left, servicing provider on the right, and both NPI fields are required.¹

Service Category and Clinical Details

Check one service category per form. Enter the diagnosis code, procedure code, time required, frequency or units, and estimated charges. The “Description of Services, DME and Supplies” field is where the request either helps the reviewer or forces them to guess. Be specific. “Power wheelchair for patient with C5 spinal cord injury, unable to self-propel manual chair” tells the reviewer what they need to know. “Wheelchair” does not.

Home Health

The home health section lists the service types: skilled nursing, physical therapy, occupational therapy, speech-language pathology, home health aide, and private duty nursing. Check each one being requested and add the anticipated discharge date. Home health requests also require the face-to-face certification described below.

Dental

Use the tooth chart to mark teeth already missing with an “X,” teeth to be extracted with a “?,” and teeth where x-rays were taken with a “V.” For dental anesthesia, put the anesthesia code and the anesthesia licensure number on the 719A alongside the related service codes.⁴

DME and Home Health Face-to-Face Certification

Federal rules require a face-to-face encounter certification for certain DME and home health requests. The requesting physician certifies the date of the encounter and identifies the prescriber who saw the patient. The form lists the allowed prescriber types: primary physician, nurse practitioner, certified nurse midwife, physician assistant, and acute or post-acute physician.¹ Leaving this section blank on a DME request that requires it is a reliable denial.

Signature and Date

The requesting provider signs and dates the form, certifying that “the services requested are medically indicated and necessary for the health of this patient and that the foregoing information is true, accurate, and complete.”¹ The dates of service you’re requesting must fall within six months of that signature date.⁴

What to Attach

The 719A is a cover sheet. What gets a request approved is the clinical documentation behind it. At a minimum, include a written justification of medical necessity, pertinent patient history, test results and lab work, current medications, and the treatment plan. Add discharge planning details and the anticipated placement provider when applicable.⁴

Several categories have their own documentation lists:

Dental and orthodontic: a written justification, x-rays or CBCT scans, a panorex if applicable, and a periodontal chart. Include a letter of necessity if the patient has cognitive, physical, or psychological impairments.⁴
Substance use disorder treatment: a completed Continuum Assessment documenting an active moderate-to-severe disorder per the DSM-5, a biopsychosocial assessment, evaluation by a qualified provider confirming medical necessity, a medical history, a comprehensive urine toxicology screen, and pregnancy test results for women or documented refusal.⁴
Out-of-state nursing home placement: a Level of Care approval letter, a completed Request for Medicaid Nursing Facility Level of Care (DHCF Form 1728) or InterRAI assessment, a Pre-Admission Screening and Annual Resident Review, a beneficiary agreement, and the patient’s history and physical with any discharge summary.⁴

Insufficient medical necessity documentation is one of the most frequent denial reasons. If the clinical picture doesn’t clearly support the requested service, the reviewer either denies or asks for more information, and either outcome costs days.

Where to Send It

DC Medicaid’s fiscal agent transitioned from Conduent to Gainwell on March 2, 2026, and all provider transactions now go through the Gainwell platform.⁵ Register as a trading partner and complete certification on the Gainwell provider portal before submitting anything.⁶

For fee-for-service prior authorizations other than acute hospital care, submit the completed 719A and supporting documents through the Gainwell portal or by fax to the number in current DHCF provider communications. For acute care hospital services involving surgical procedures, transplants, medical procedures, and testing, use the Comagine Health Provider Portal starting May 4, 2026.² MCO enrollees go through their plan’s own portal and fax number. Keep the electronic submission receipt or fax transmission report for every request.

How Long a Decision Takes

The District’s Prior Authorization Reform Amendment Act of 2023 sets these deadlines, starting when the reviewer has all the information needed to decide:

Urgent services: 24 hours. A service is urgent when, in a physician’s opinion, delay could seriously jeopardize the patient’s life, health, or ability to regain maximum function, or subject the patient to severe pain that can’t be adequately managed without the requested care. Medication-assisted treatment also qualifies.⁷
Long-term services and supports: 30 days, provided the enrollee has already been determined eligible for Medicaid benefits.⁷
All other services: 3 business days for electronic portal submissions, or 5 business days for mail, phone, or fax.⁷

A service is deemed approved if the reviewer doesn’t issue notice within these timeframes.⁷ Note the trigger, though: the clock runs from when the reviewer has everything they need, not when you hit send. A request for additional documentation resets the timeline once you respond.

Why Requests Get Denied or Delayed

Most problems come from a short list of recurring mistakes:

Blank fields, especially the DCID number, NPI, diagnosis code, or procedure code.
Clinical documentation that doesn’t clearly support medical necessity for this patient.
A missing face-to-face certification on a DME or home health request that requires one.
Sending the request to the wrong channel: a fee-for-service request to an MCO portal, an MCO request to Gainwell, or acute hospital services outside the Comagine portal after May 2026.
Requested dates of service that fall outside the six-month window from the signature date.⁴

If Your Request Is Denied

Both providers and beneficiaries can challenge a denial. The path depends on coverage: MCO enrollees typically start with the plan’s internal appeal, and fee-for-service denials go through DHCF first. If the internal review doesn’t resolve the dispute, either party can request a hearing at the D.C. Office of Administrative Hearings using its Medicaid Provider Appeal Form.⁸ Watch the filing deadline. Missing it waives the right to a hearing.

Retrospective requests for services already delivered face a tougher standard. Services that could have been provided in network are unlikely to be approved after the fact unless the care was urgent, emergent, or a continuity-of-care issue. Emergency services are paid under the prudent layperson standard regardless of prior authorization status.

1
Department of Health Care Finance. 719A Prior Authorization Request
2
District of Columbia Medicaid. District of Columbia Medicaid
3
Centers for Medicare & Medicaid Services. National Provider Identifier Standard
4
Comagine Health. Utilization Review Quality Improvement Organization Provider Manual
5
Department of Health Care Finance. DC Medicaid Fiscal Agent Transition Summary
6
Department of Health Care Finance. Portal Registration Is Live
7
D.C. Law Library. D.C. Law 25-100 – Prior Authorization Reform Amendment Act of 2023
8
Office of Administrative Hearings. OAH Forms