Get Acs 719a 2010-2025

The ACS 719A form is a crucial document utilized for requesting prior authorizations for medical services and supplies. Accurately completing this form is essential to ensure timely processing and to prevent delays in obtaining necessary healthcare services.

Follow the steps to complete the ACS 719A form online.

1. Press the ‘Get Form’ button to access the ACS 719A form and open it in the appropriate editor.
2. Enter the billing provider’s Medicaid number in the designated space and print the name of the billing provider who is seeking reimbursement.
3. In Block 1, input the recipient’s Medicaid number, full name, address, telephone number, and date of birth.
4. In Block 2, provide the requesting provider’s Medicaid number, name, and complete address, including the telephone number.
5. For Block 3, enter the details of any other health insurance coverage, including the policy holder's name and plan details, or leave it blank if not applicable.
6. In Block 4, select the appropriate block that corresponds to the requested service or equipment.
7. In Block 5, accurately describe the patient's location—select the appropriate block and enter the discharge date if still in a facility.
8. In Block 6, input the diagnosis code that reflects the patient's condition and justifies the requested services.
9. Block 7 requires entry of the HCPCS code for the requested service or equipment, including any applicable modifiers.
10. In Block 8, provide a thorough description of the requested equipment or service as per the HCPCS Coding Manual.
11. In Block 9, estimate the time required for the service or equipment.
12. Block 10 necessitates the entry of the number of units or services needed to meet the patient’s requirements.
13. In Block 11, record the estimated charge for the service or equipment.
14. Block 12 will be completed by the Department of Health Care Finance with the approved reimbursement amount.
15. In Block 13, provide the medical justification for the requested supplies or services and note the date of service.
16. In Block 15, ensure the form is signed and dated by the requesting provider, indicating the effective date.
17. Once all fields are completed, review the form for accuracy. You can save changes, download, print, or share the completed form as needed.

Complete your ACS 719A form online today to facilitate your prior authorization requests.