How to complete Medical necessity form - Part 1

Completion of Certificate of Medical Necessity Forms


1. SECTION A: (This may be completed by supplier.)

a. Certification Type/Date - If this is an initial certification for this patient, the date (MM/DD/YY) is indicated in the space marked "INITIAL". If this is a revised certification (to be completed when the physician changes the order, based on the patient's changing clinical needs), the initial date is indicated in the space marked "INITIAL", and the revision date is indicated in the space marked "REVISED". If this is a recertification, the initial date is indicated in the space marked "INITIAL", and the recertification date is indicated in the space marked "RECERTIFICATION". Whether a REVISED or RECERTIFIED CMN is submitted, the INITIAL date as well as the REVISED or RECERTIFICATION date is always furnished.


b. Patient Information - This indicates the patient's name, permanent legal address, telephone number, and his/her health insurance claim number (HICN) as it appears on his/her Medicare card and on the claim form.

c. Supplier Information - This indicates the name of the company (supplier name), address, telephone number, and the Medicare supplier number assigned by the National Supplier Clearinghouse (NSC).

d. Place of Service - This indicates the place in which the item is being used, i.e., patient's home is 12, skilled nursing facility (SNF) is 31, or end stage renal disease (ESRD) facility is 65. See chapter 23 for place of service codes.

e. Facility Name - This indicates the name and complete address of the facility, if the place of service is a facility.

f. HCPCS Codes - This is a list of all HCPCS procedure codes for items ordered that require a CMN. Procedure codes that do not require certification are not listed on the CMN.

g. Patient Date of Birth (DOB), Height, Weight, and Sex - This indicates patient's DOB (MM/DD/YY), height in inches, weight in pounds, and sex (male or female).

h. Physician Name and Address - This indicates the treating physician's name and complete mailing address.

i. UPIN - This indicates the treating physician's unique physician identification number (UPIN).- Replaced by NPI

j. Physician's Telephone Number - This indicates the telephone number where the treating physician can be contacted (preferably where records would be accessible pertaining to this patient) if additional information is needed.