Interactive Durable Medical Equipment & Supply ......Interactive Durable Medical Equipment & Supply Documentation Guidelines Confidentiality Notice: Information contained on this site

InteractiveDurable Medical Equipment & Supply Documentation GuidelinesConfidentiality Notice: Information contained on this site is proprietary in nature, and offered for the use of registered individuals only. You are hereby notified that any disclosure, copying, or distribution of the information is strictly prohibited.

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MEDICARE REGULATIONSNORIDIAN FACE TO FACE WRITTEN ORDER REQUIREMENTS ..................................................................... 4-6AMBULATORY AIDSCOVERAGE CRITERIA FOR WALKERS CANES AND CRUTCHES ...................................................................... 7PRESCRIPTION FOR CANES AND CRUTCHES ..................................................................................................... 8PRESCRIPTION FOR WALKERS .................................................................................................................................. 9COVERAGE CRITERIA FOR MANUAL WHEELCHAIRS ....................................................................................... 10PRESCRIPTION FOR MANUAL WHEELCHAIRS ..................................................................................................... 11

BATHROOM SAFETYCOVERAGE CRITERIA FOR BATHROOM AIDS ..................................................................................................... 12PRESCRIPTION FOR HYGIENE AND BATH AIDS ................................................................................................. 13COVERAGE CRITERIA FOR COMMODES .............................................................................................................. 14PRESCRIPTION FOR COMMODES ........................................................................................................................... 15

HMECOVERAGE CRITERIA FOR GROUP 1 SUPPORT SURFACES ........................................................................... 16PRESCRIPTION FOR GROUP 1 SUPPORT SURFACES ........................................................................................ 17COVERAGE CRITERIA FOR GROUP 2 SUPPORT SURFACES .......................................................................... 18PRESCRIPTION FOR GROUP 2 SUPPORT SURFACES ....................................................................................... 19COVERAGE CRITERIA FOR HOSPITAL BEDS AND ACCESSORIES ............................................................... 20PRESCRIPTION FOR GROUP HOSPITAL BEDS AND ACCESSORIES ............................................................ 21COVERAGE CRITERIA FOR LIFT CHAIRS AND SEAT MECHANISMS ............................................................ 22(USE OPEN PRESCRIPTION AT BACK OF BINDER)COVERAGE CRITERIA FOR PATIENT LIFT ............................................................................................................ 23PRESCRIPTION FOR PATIENT LIFT AND SLING .................................................................................................. 24PRESCRIPTION FOR EQUIPMENT MAINTENANCE AND REPAIR .................................................................. 25

RESPIRATORY COVERAGE CRITERIA FOR AEROSOL SYSTEM (LARGE VOLUME NEBULIZER) ....................................... 26PRESCRIPTION (CMN) FOR AEROSOL TRACHE CARE SUPPLY ..................................................................... 27COVERAGE CRITERIA FOR COUGH ASSIST ....................................................................................................... 28COVERAGE CRITERIA FOR NEBULIZERS ............................................................................................................. 29PRESCRIPTION (CMN) FOR NEBULIZER EQUIPMENT AND SUPPLY ............................................................ 30COVERAGE CRITERIA FOR OXYGEN ...................................................................................................................... 31PRESCRIPTION FOR OXYGEN EQUIPMENT AND SUPPLY .............................................................................. 32

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RESPIRATORY CONT...CMN FOR OXYGEN (CMS484) ........................................................................................................................... 33-34COVERAGE CRITERIA FOR RESPIRATORY ASSIST DEVICE ...................................................................... 35-36COVERAGE CRITERIA FOR CPAP AND BIPAP FOR OBSTRUCTIVE SLEEP APNEA ................................. 37PRESCRIPTION PAP/RAD ........................................................................................................................................... 38PRESCRIPTION FOR PAP/RAD RESUPPLY ............................................................................................................ 39COVERAGE CRITERIA FOR PHOTOTHERAPY ..................................................................................................... 40PRESCRIPTION FOR PHOTOTHERAPY SYSTEM ................................................................................................. 41COVERAGE CRITERIA SUCTION MACHINE AND SUPPLIES ........................................................................... 42PRESCRIPTION FOR SUCTION MACHINE AND SUPPLIES .............................................................................. 43COVERAGE CRITERIA FOR VENTILATOR ............................................................................................................. 44PRESCRIPTION FOR VENTILATOR AND SUPPLIES ........................................................................................... 45

ENTERALCOVERAGE CRITERIA FOR ENTERAL NUTRITION AND FEEDING PUMP ................................................... 46PRESCRIPTION FOR ENTERAL EQUIPMENT AND SUPPLIES ......................................................................... 47

INCONTINENCE/UROLOGY/OSTOMYCOVERAGE CRITERIA FOR INCONTINENCE SUPPLIES ................................................................................... 48PRESCRIPTION (CMN) FOR INCONTINENCE SUPPLIES ............................................................................ 49-50COVERAGE CRITERIA FOR OSTOMY SUPPLIES ................................................................................................. 51PRESCRIPTION FOR OSTOMY SUPPLIES . ............................................................................................................ 52COVERAGE CRITERIA FOR UROLOGICAL SUPPLIES ....................................................................................... 53PRESCRIPTION FOR UROLOGICAL SUPPLIES .................................................................................................... 54

WOUND/COMPRESSION COVERAGE CRITERIA FOR COMPRESSION GARMENTS ................................................................................ 55PRESCRIPTION (CMN) FOR COMPRESSION GARMENTS ................................................................................ 56COVERAGE CRITERIA FOR WOUND SUPPLIES .................................................................................................. 57PRESCRIPTION FOR WOUND SUPPLY ........................................................................................................... 58-59OPEN PRESCRIPTION ................................................................................................................................................. 60OPEN CMN (FORM ONLY) .................................................................................................................................... 61-62LIST OF ITEMS THAT NEED LETTER OF JUSTIFICATION FROM PHYSICIAN’S OFFICE ......................... 63ALASKA MEDICAID SERVICE AUTHORIZATION RELEASE FORM ................................................................. 64

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Cane & Crutch Prescription

RXHMECAC092016

Caneq Standard q Quad q Bariatric Needed (over 300 lbs) q Ice Grips_______________________________________________________________________________________

Crutchq Standard q Forearm q Bariatric Needed (over 300 lbs) q Ice Grips (2)_______________________________________________________________________________________

The mobility-related activities of daily living (MRADLs) being affected in the home are

(please select all that apply):

q Bathing q Dressing q Grooming q Toileting q Feeding_______________________________________________________________________________________

The patient has a mobility limitation that (select):

q Prevents the patient from accomplishing the MRADL entirely, or

q Places the patient at reasonably determined heightened risk of morbidity or mortality secondary

to the attempts to perform an MRADL, or

q Prevents the patient from completing the MRADL within a reasonable time frame._______________________________________________________________________________________

q The patient is able to safely use the cane or crutch. _______________________________________________________________________________________

q The functional mobility deficit can be sufficiently resolved by the use of a cane or crutch.

Patient’s current height (inches) _____________ Patient’s current weight (lbs.) _____________

Prescriber Signature: ________________________________________________ Date: _________________

Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________

ICD-10 Code: _________________ Description:

Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________

Length of Need (in months): __________


Walker Prescription

RXHMEW092016

Equipmentq Walker without wheels q 2 wheeled walker q 3 wheeled walkerq Platform attachment q 4 wheeled walker with seat attachment and multiple braking system_______________________________________________________________________________________The mobility-related activities of daily living (MRADLs) being affected in the home are (select all that apply): q Bathing q Dressing q Grooming q Toileting q Feeding_______________________________________________________________________________________The patient has a mobility limitation that (select):q Prevents the patient from accomplishing the MRADL entirely, orq Places the patient at reasonably determined heightened risk of morbidity or mortaility secondary to the attempts to perform an MRADL, orq Prevents the patient from completing the MRADL within a reasonable time frame._______________________________________________________________________________________

q The functional mobility deficit can be sufficiently resolved with the use of a walker._______________________________________________________________________________________

q Patient is safely able to use the walker_______________________________________________________________________________________

q Patient has a severe neurologic disorder or other condition causing restricted use of one hand.

q Heavy duty, multiple braking system, variable wheel resistance walker_______________________________________________________________________________________


q Bariatric equipment needed (over 300 lbs.)


Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________




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Wheelchair Manual Prescription

RXHMEWM092016

Equipmentq Manual wheelchair with seatbelt and anti-tippers

q Lightweight wheelchair with seatbelt and anti-tippers

q Heavy Duty (more than 250 lbs) wheelchair with seatbelt and anti-tippers

q Extra Heavy Duty (more than 300 lbs) with seatbelt and anti-tippers_______________________________________________________________________________________

AccessoriesLeg rests (select type) q Standard q Elevating q Articulating

q Standard Seat Cushion q Skin Protectant Cushion q Pressure Relieving Positioning Cushion

q Padded Solid Back Seat q Reclining Back

q Oxygen tank holder_______________________________________________________________________________________

Does your patient have positioning needs that require any of the following (PT eval generally required)?

(Select all that apply)

q Tilt-in-Space q Custom Seating q Pediatric Sizing (lifetime need)



Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________




Equipment

Bath chair with back

Bath chair without back

Raised toilet seat (select one) Standard Elongated

Grab bar (select size) 12in 16in 18in 24in 32in Quantity needed _____

Bath transfer bench

Hand held shower head

Toilet safety frame

Tub grab bar with clamp

Hygiene & Bath Aids Prescription

RXHMEBAP092016

Patient’s current height (inches) _____________ Patient’s current weight (lbs) _____________


Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________




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Commode Prescription

RXHMECOM092016

Commodeq Stationary q Mobile

q Detachable Arms q Fixed Arms q Drop Arm

q Pail or pan for use with commode_______________________________________________________________________________________

Height: ___________ Weight: ___________

Patients over 300 lbs. q Extra Wide q Heavy Duty_______________________________________________________________________________________

PLEASE SELECT:

q Mypatientisconfinedtosingleroom.

q Mypatientisconfinedtoonelevelofhomeandthereisnotoilet.

q Mypatientisconfinedtothehomeandthereisnotoilet.


Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________




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Group 1 Support Surface Prescription

RXHMEGRP1092016

Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Equipment q Alternating Pressure Pad and Pump qReplacement Pad qGel Foam Overlay _______________________________________________________________________________________ q Patient is completely immobile qPatient has limited mobility_______________________________________________________________________________________

q Patient has any stage pressure ulcer on the trunk or pelvis (please provide ICD-10 code above)_______________________________________________________________________________________

q Patient is completely immobile qPatient has limited mobility _______________________________________________________________________________________Patient has one of the following (please select all that apply):q Impaired nutritional status qFecal Incontinence qUrinary Incontinence q Altered sensory perception qCompromised circulatory status_______________________________________________________________________________________

q Patient has a care plan that contains the following (when applicable to patient’s condition):1. Educationofthebeneficiaryandcaregiveronthepreventionand/ormanagementofpressureulcers2. Regular assessment by a nurse, physician, or other licensed healthcare practitioner3. Appropriate turning and positioning4. Appropriate wound care (for a stage II, III, or IV ulcer)5. Appropriatemanagementofmoisture/incontinence6. Nutritional assessment and intervention

Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________






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Group 2Support Surface Prescription

RXHMEGRP2092016

Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Equipment q Micro Air Mattress

Patient’s current height (inches) _____________ Patient’s current weight (lbs.) ____________________________________________________________________________________________________ Patient has one of the following (please provide ICD-10 code above):

q Multiple Stage II pressure ulcers on trunk or pelvis that have failed to heal over the past month

q Large or multiple Stage III or IV Pressure ulcers on the trunk or pelvis

q Myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within_______________________________________________________________________________________

q Patient’s stage II pressure ulcers have worsened or remained the same over the last month

q Patient has been on a comprehensive ulcer treatment program for the past month, including a. Use of an appropriate group 1 support surface b. Regular assessment by a nurse, physician, or other licensed healthcare practitioner c. Appropriate turning and positioning d. Appropriate wound care e. Appropriate management of _______________________________________________________________________________________q Patient was placed on a group 2 or group 3 support surface immediately prior to discharge from hospital or nursing facility within the past 30 days_______________________________________________________________________________________q Patient has a care plan established to address all of the conditions selected above

Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________





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Hospital Bed & Accessories Prescription

RXHMEHB092016

Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Equipment q Semi-Electric hospital bed with mattress and side rails

q Full Electric hospital bed with mattress and side rails

q Trapeze qBed cradle qOver the bed table qReplacement mattress

qBariatric equipment needed (over 300 lbs)_______________________________________________________________________________________ q Patient has a medical condition that requires body positioning in ways not feasible w/ an ordinary bed_______________________________________________________________________________________ q Patient requires frequent changes in body position or has an immediate need for a change in body position_______________________________________________________________________________________ q Hospital bed is required for the alleviation of pain that is not feasible with an ordinary bed_______________________________________________________________________________________ q Patient requires elevation of head or upper body to be at least 30 degrees due to congestive heart

failure, chronic pulmonary disease, or problems with aspiration_______________________________________________________________________________________ q Patient requires traction equipment which can only be attached to a hospital bed_______________________________________________________________________________________ q Patient requires trapeze equipment to sit up because of a respiratory condition, to change body position

for other medical reasons, or to get in or out of bed

Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________


Patient’s current height (in inches) _____________ Patient’s current weight (in pounds) _____________




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Patient Lift & Sling Prescription

RXHMEPLS092016

Equipment

q Hydraulic patient lift

q Medical records supports that patient requires the assistance of more than one person for transfer

betweenbedandchair,wheelchairorcommodeandwithoutthelift,patientwouldbebedconfined.

Sling options (please select)

q Divided Leg qFull Body

q Mesh qCanvas

q Head Support

q Commode Opening

Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________



Patient’scurrentheight(inches)_____________Patient’scurrentweight(lbs.)_____________


Equipment Maintenance & Repair Prescription

RXHMEEM092016

Equipment Maintenance

All parts, labor, and repair for patient owned:

q Manual Wheelchair qPower Wheelchair

q Hospital Bed qPatient Lift qSupport Surface qWalker

q CPAP/BIPAP Machine qOxygen Equipment qNebulizer

q Feeding pump qIV Pole

q Other ______________________________________________________________________

q One month rental of like equipment being repaired


Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________




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Equipment: Heated aerosol compressor with J tube assembly

Trach tube:____/mo. Size: _________ Brand: ________ Cuffed Cuffless Fenestrated Non-Fenestrated

______________________________________________________________________________________Monthly UsageInner cannula Size __________ 30/month Other __________

Suction catheter kit with glove Size __________ 200/month Other ________________________________________________________________________________________________Monthly UsageTracheostomy care kit 30/month Other __________

Tracheostomy collar/holder 30/month Other __________

Trach aerosol mask 4/month Other __________

Aerosol tubing 100 ft./month Other __________

Passy muir valve 1/month Other __________

Thermovent T adapters 100/month Other __________

Thera-mist nebulizer adapter 4/Month Other __________

Oxygen bleed in adapter/Pressure line adaptor 4/month Other __________

Sterile H20 for inhalation (1000 ml) for aerosol 30/month Other __________

Sterile water (250 ml) for trach care 20/month Other __________

Hydrogen peroxide (480 ml) 10/month Other __________

Water drain bags 4/month Other __________

4x4 drain sponge 150/month Other __________

Omniflex adapters 10/month Other __________

Resuscitation Bag 1/each

Aerosol/Trach Equipment & Supplies Prescription

RXHMEATCS092016


Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________




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Equipment

Nebulizer and Aerosol compressor

______________________________________________________________________________________Name, concentration, and frequency of drug being administered:

______________________________________________________________________________________Supplies

Aerosol mask 1/month Other Qty _____

Tracheostomy mask 4/month Other Qty _____

Disposable nebulizer kit 2/month Other Qty _____

Disposable filter 1 every 3 months Other Qty _____

Non-Disposable nebulizer kit 1 every 6 months Qty _____

Nebulizer and Supplies Prescription

RXHMENES092016


Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________




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Equipment Oxygen concentrator

Portable oxygen concentrator

Homefill system

Regulator with cart and stand

Conserving regulator with cart and stand

______________________________________________________________________________________

Oxygen Saturation Test Results Date ______________

At rest on room air _____ %

During exercise on room air _____ %

During exercise with oxygen _____ %

During sleep _____ %______________________________________________________________________________________

Liters Per Minute _______ Hours Per Day _______ ______________________________________________________________________________________

Method of Delivery (please select): Nasal cannula Oxygen Mask CPAP/BIPAP Ventilator

______________________________________________________________________________________

Oxygen Tank Usage (per month)

Cubic Feet Needed __________ (E tank=25 cf, D tank=15 cf, C tank=9 cf)

______________________________________________________________________________________

Monthly Supplies Tubing 2/month Tubing Connectors 2/month Water Trap 1/month Oxygen Mask 1/month

Humidifier Bottle 1/month Nasal Cannula 2/month Filters 1 every other month

Oxygen Equipment & Supply CMN Form

RXHMEOES092016

Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________


Prescriber Signature: ________________________________________________ Date: _________________Return to Table of Contents

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1Form CMS-484 (11/11)

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

Form ApprovedOMB No. 0938-0534

CERTIFICATE OF MEDICAL NECESSITY CMS-484 — OXYGEN

DME 484.3

SECTION A: Certification Type/Date: INITIAL / / REVISED / / RECERTIFICATION / /

PATIENT NAME, ADDRESS, TELEPHONE and HICN

( ) – HICN (

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI #

NSC or NPI #

PLACE OF SERVICE SUPPLY ITEM/SERVICE PROCEDURE CODE(S) / PT DOB Sex (M/F) Ht. (in) Wt.

NAME and ADDRESS of FACILITY if applicable (see reverse)

–

PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN or NPI #

( UPIN or NPI #

SECTION B: Information in this Section May Not Be Completed by the Supplier of the Items/Supplies.

EST. LENGTH OF NEED (# OF MONTHS): 1–99 (99=LIFETIME) DIAGNOSIS CODES:

ANSWERS ANSWER QUESTIONS 1–9. (Check Y for Yes, N for No, or D for Does Not Apply, unless otherwise noted.)

a) mm Hg

b) %

c) / /

1. Enter the result of most recent test taken on or before the certification date listed in Section A. Enter (a) arterial blood gas PO2 and/or (b) oxygen saturation test; (c) date of test.

1 2 3 2. Was the test in Question 1 performed (1) with the patient in a chronic stable state as an outpatient, (2) within two days prior to discharge from an inpatient facility to home, or (3) under other circumstances?

1 2 3 3. Check the one number for the condition of the test in Question 1: (1) At Rest; (2) During Exercise; (3) During Sleep

Y N D4. If you are ordering portable oxygen, is the patient mobile within the home? If you are not ordering

portable oxygen, check D.

LPM 5. Enter the highest oxygen flow rate ordered for this patient in liters per minute. If less than 1 LPM, enter an “X”.

a) mm Hg

b) %

c) / /

6. If greater than 4 LPM is prescribed, enter results of most recent test taken on 4 LPM. This may be an (a) arterial blood gas PO2 and/or (b) oxygen saturation test with patient in a chronic stable state. Enter date of test (c).

ANSWER QUESTIONS 7–9 ONLY IF PO2 = 56–59 OR OXYGEN SATURATION = 89 IN QUESTION 1

7. Does the patient have dependent edema due to congestive heart failure?Y N

8. Does the patient have cor pulmonale or pulmonary hypertension documented by P pulmonale on an EKG or by an echocardiogram, gated blood pool scan or direct pulmonary artery pressure measurement?

Y N

9. Does the patient have a hematocrit greater than 56%? Y NNAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print):

NAME TITLE EMPLOYER

SECTION C: Narrative Description of Equipment and Cost(1) Narrative description of all items, accessories and options ordered; (2) Suppliers charge; and (3) Medicare Fee Schedule Allowance for each item, accessory, and option (see instructions on back)

SECTION D: PHYSICIAN Attestation and Signature/Date I certify that I am the treating physician identified in Section A of this form. I have received Sections A, B and C of the Certificate of Medical Necessity (including charges for items ordered). Any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that the medical necessity information in Section B is true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability.

PHYSICIAN’S SIGNATURE DATE Signature and Date Stamps Are Not Acceptable.

Form CMS-484 (11/11) INSTRUCTIONS

INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY FOR OXYGEN SECTION A: (May be completed by the supplier)

CERTIFICATION DATE: If this is an initial certification for this patient, indicate this by placing date (MM/DD/YY) needed initially in the space TYPE/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), indicate the initial date needed in the space marked “INITIAL,” and indicate the recertification date in the space marked “REVISED.” If this is a recertification, indicate the initial date needed in the space marked “INITIAL,” and indicate the recertification date in the space marked “RECERTIFICATION.” Whether submitting a REVISED or a RECERTIFIED CMN, be sure to always furnish the INITIAL date as well as the REVISED or RECERTIFICATION date.

PATIENT INFORMATION: Indicate 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.

SUPPLIER INFORMATION: Indicate the name of your company (supplier name), address and telephone number along with the Medicare Supplier Number assigned to you by the National Supplier Clearinghouse (NSC) or applicable National Provider Identifier (NPI). If using the NPI Number, indicate this by using the qualifier XX followed by the 10-digit number. If using a legacy number, e.g. NSC number, use the qualifier 1C followed by the 10-digit number. (For example. 1Cxxxxxxxxxx)

PLACE OF SERVICE: Indicate the place in which the item is being used, i.e., patient’s home is 12, skilled nursing facility (SNF) is 31, End Stage Renal Disease (ESRD) facility is 65, etc. Refer to the DMERC supplier manual for a complete list.

FACILITY NAME: If the place of service is a facility, indicate the name and complete address of the facility.

SUPPLY ITEM/SERVICE PROCEDURE CODE(S):

List all procedure codes for items ordered. Procedure codes that do not require certification should not be listed on the CMN.

PATIENT DOB, HEIGHT, WEIGHT AND SEX:

Indicate patient’s date of birth (MM/DD/YY) and sex (male or female); height in inches and weight in pounds, if requested.

PHYSICIAN NAME, ADDRESS: Indicate the PHYSICIAN’S name and complete mailing address.

PHYSICIAN INFORMATION: Accurately indicate the treating physician’s Unique Physician Identification Number (UPIN) or applicable National Provider Identifier (NPI). If using the NPI Number, indicate this by using the qualifier XX followed by the 10-digit number. If using UPIN number, use the qualifier 1G followed by the 6-digit number. (For example. 1Gxxxxxx)

PHYSICIAN’S TELEPHONE NO: Indicate the telephone number where the physician can be contacted (preferably where records would be accessible pertaining to this patient) if more information is needed.

SECTION B: (May not be completed by the supplier. While this section may be completed by a non-physician clinician, or a Physician employee, it must be reviewed, and the CMN signed (in Section D) by the treating practitioner.)

EST. LENGTH OF NEED: Indicate the estimated length of need (the length of time the physician expects the patient to require use of the ordered item) by filling in the appropriate number of months. If the patient will require the item for the duration of his/her life, then enter “99”.

DIAGNOSIS CODES: In the first space, list the diagnosis code that represents the primary reason for ordering this item. List any additional diagnosis codes that would further describe the medical need for the item (up to 4 codes).

QUESTION SECTION: This section is used to gather clinical information to help Medicare determine the medical necessity for the item(s) being ordered. Answer each question which applies to the items ordered, checking “Y” for yes, “N” for no, or “D” for does not apply.

NAME OF PERSON ANSWERING SECTION B QUESTIONS:

If a clinical professional other than the treating physician (e.g., home health nurse, physical therapist, dietician) or a physician employee answers the questions of Section B, he/she must print his/her name, give his/her professional title and the name of his/her employer where indicated. If the physician is answering the questions, this space may be left blank.

SECTION C: (To be completed by the supplier)

NARRATIVE DESCRIPTION OF EQUIPMENT & COST:

Supplier gives (1) a narrative description of the item(s) ordered, as well as all options, accessories, supplies and drugs; (2) the supplier’s charge for each item(s), options, accessories, supplies and drugs; and (3) the Medicare fee schedule allowance for each item(s), options, accessories, supplies and drugs, if applicable.

SECTION D: (To be completed by the physician)

PHYSICIAN ATTESTATION: The physician’s signature certifies (1) the CMN which he/she is reviewing includes Sections A, B, C and D; (2) the answers in Section B are correct; and (3) the self-identifying information in Section A is correct.

PHYSICIAN SIGNATURE AND DATE:

After completion and/or review by the physician of Sections A, B and C, the physician’s must sign and date the CMN in Section D, verifying the Attestation appearing in this Section. The physician’s signature also certifies the items ordered are medically necessary for this patient.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0534. The time required to complete this information collection is estimated to average 12 minutes per response, including the time to review instructions, search existing resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Blvd. Baltimore, Maryland 21244.

DO NOT SUBMIT CLAIMS TO THIS ADDRESS. Please see http://www.medicare.gov/ for information on claim filing.


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Equipment & Pressure Settings

CPAP _______ cmH20

Auto CPAP _______ cmH20

BIPAP _______ cmH20

Auto BIPAP _______ cmH20

BIPAP Auto SV Mode _____________

______________________________________________________________________________________Does the patient have any of the following diagnoses? G47.31 G47.33 G47.37

______________________________________________________________________________________Mask Type must be selected for Medicare recipients (cannot indicate patient preference):

Full face mask w/ headgear every 3 months, with 1 FF cushion every month

Nasal mask w/ headgear every 3 months, with 2 nasal cushions or 2 nasal pillows per month

______________________________________________________________________________________

Accessories & Supplies

Every6months:1chinstrap,1waterchamber,1nondisposablefilter

Every 3 months: 1 heated tubing OR non-heated tubing

Everymonth:2disposablefilters

Pressure line adapter for O2 bleed in 1/month (select if needed)

PAP/RAD Prescription

RXHMEPAP092016

Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________




Does the patient have any of the following diagnoses? G47.31 G47.33 G47.37

______________________________________________________________________________________Mask Type must be selected for Medicare recipients (cannot indicate patient preference):

Full face mask w/ headgear every 3 months, with 1 FF cushion every month

Nasal mask w/ headgear every 3 months, with 2 nasal cushions or 2 nasal pillows per month

______________________________________________________________________________________

Supplies

Every6months:1chinstrap,1waterchamber,1nondisposablefilter

Every 3 months: 1 heated tubing OR non-heated tubing

Everymonth:2disposablefilters

Pressure line adapter for O2 bleed in 1/month (select if needed)

PAP/RAD Resupply Prescription

RXHMEPRES092016

Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________

Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________





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Phototherapy System Prescription

RXHMEPHOTO092016

Phototherapy Device (AKA Biliblanket) to aid in lowering bilirubin levels in infants

What is the Irradiance Setting? q High q Low


Estimated discontinue date (mm/dd/yy)? __________________________

Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________





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Equipment Suction machine

______________________________________________________________________________________

Monthly Supplies Yankauer Suction Tubes 4/month Other Qty ____ Suction Catheter Kits _____ Size _____/month

3-4’ connective suction tubing 1/month Other Qty ____ 6 ft connective tubing 2/month Other Qty ____

1 ft connective suction tubing 1/month Other Qty ____ Disposable canisters 2/month Other Qty ____

90 degree elbow adapter 1/month Other Qty ____ Suction tooth brushes 30/month Other Qty ____

Bacterial Filter 1/month Other Qty ____

______________________________________________________________________________________

Is the patient unable to handle secretions? Yes No

______________________________________________________________________________________

Does the patient have cancer or surgery of the mouth? Yes No

______________________________________________________________________________________

Does the patient have a dysfunction of swallowing muscles? Yes No

______________________________________________________________________________________

Is the patient in an unconscious or obtunded state? Yes No

______________________________________________________________________________________

Does the patient have a tracheotomy? Yes No

Suction Machine & Supplies Prescription

RXHMESMS092016

Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________





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Equipment Ventilator machine Monthly respiratory therapist home visit

Ventilator make __________________ Ventilator model __________________ Ventilation mode __________________ ______________________________________________________________________________________Settings Vt _____________ ml Rate _____________ Inspiration Time ___________ Sigh On Off

Pressure __________ PS _______________ EPAP/PEEP_______________

___________ AVAPS IPAP min __________ IPAP max ________________ Vt Target ________________________________________________________________________________________________Settings Supplemental Oxygen: FIO2 /lpm __________ Titrate O2 to maintain SaO2 > __________

Humidification: Heated Humidifier HME

Patient Interface: Mask Trach tube

Hours of use: During sleep Continuously Other: ________________________________________________________________________________________________________________________________Accessories Ventilator stand Ventilator carrying case

Ventilator external battery with charger and carrying case Heated humidifier______________________________________________________________________________________Monthly Supplies Disposable dual heated ventilator circuit w/peep 2/month Other Qty ___

Water Chamber 2/month Other Qty ___

Heated humidifier cables 1/month Other Qty ___

Vent inlet filters 5/month Other Qty ___

Omniflex adaptors 15/month Other Qty ___

Bacteria filters 1/month Other Qty ___

Vent fan filters 5/month Other Qty ___

Sterile H20 for inhalation (1,000ml bottle) 30/month Other Qty ___

Temperature probe 1/month Other Qty ___

Pollen filter 1/6 months Other Qty ___

Ventilator & Supplies Prescription

RXHMEVS092016

Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________


Prescriber Signature: ________________________________________________ Date: _________________Return to Table of Contents


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Enteral Equipment & Supplies Prescription

RXHMEENT092016

Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Oral Formula Brand _____________________________________________

Calories Per Day Required _________ Substitution Allowed q Yes q No

_______________________________________________________________________________________ Tube Fed Formula Brand _____________________________________________

Calories Per Day Required _________ Substitution Allowed q Yes q No

q Feeding pump _____mls/hr _____hours per day

q Gravity _____mls every _____hours or _____times per day

q Syringe _____mls every _____hours or _____times per day_______________________________________________________________________________________

Monthly Supplies Please specify quantity per month for each item (box amounts not valid)

______ Feeding Bags (select size): q 500 ml q 1000 ml (select type): q Pump q Gravity

______ Gauze (select size): q 4x4 q 2x2 ____ 60 ml Syringe ____ Extension Tube ____ Y Port Connector

______ Decompression Tube ____ Sterile Water (1000 ml Bottle)

______ Tape Roll (select size): q 1” q 2” q 3” (select type): q Waterproof q Non-Waterproof_______________________________________________________________________________________

q Feeding pump with alarm & IV pole (medical record indicates client is unable to tolerate syringe & gravity feedings)_______________________________________________________________________________________

Feeding Tube Gastrostomy Tube _______/monthly _______ FR _______ cm q Standard q Low profile

Jejunostomy Tube _______/monthly _______ FR _______ cm

Nasogastric Tube _______/monthly _______ FR _______ cm

Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________





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Certificate of Medical Necessity for Incontinence Supplies, Page 1 of 2

MEMBER INFORMATION PROVIDER INFORMATIONMember Name: (Last, First, MI)

Alaska Medicaid Member ID:

Date of Birth (MM/DD/YY): __________ Age:_____ Sex: _____

Ordering Provider’s Name: ______________________________

Provider Medicaid ID or NPI: _____________________________

Phone Number: _______________________ Ext. ___________

*Height: _____ (inches) *Weight: ______ (pounds)

Date of last visit: ___________________

Prescription Start Date: ________________

Retrospective Review? Yes No

SECTION A - CLINICAL INFORMATION (This section MUST be completed by the attending physician, physician assistant, or nurse practitioner.)Diagnosis Code Diagnosis Description

ICD-9

Enter the corresponding ICD-10 diagnosis code and description if requested services/items extend beyond September 30th, 2015.

ICD-10

Estimated Length of Need (# of Months): _______ (99 = Lifetime)SECTION B - CLINICAL ASSESSMENT OF NEED FOR PRESCRIBED SERVICES OR ITEM(S) AND PLANAnnotate the medical justification, as it pertains to the member’s specific diagnosis, indicating the medical necessity of the requested services or items. Attach any supporting documentation as needed for further justification. (This section may be completed by the attending physician, physician assistant, or nurse practitioner within the scope of his or her specialty.)

PLAN: The plan should list each service or item specifically needed for the treatment of the member. Additional treatment information may be attached to this form.

Daily Usage Supplies (mark appropriate quantity): Monthly Usage Supplies (mark appropriate quantity):

Disposable Brief / Undergarment Other Qty ____* Reusable Bed Pads w/ or w/o Flaps Other Qty ____* 1 2 3 4 5 6 7 8 1 2 3 4

Insert Pads (used in briefs) Other Qty ____* Gloves (per month) Other Qty ____*1 2 3 4 5 6 7 8 100 200 300 400

Disposable Bed Pads Other Qty ____* Moisture Barrier Ointment/Gel** Other Qty ____*1 2 3 4 5 1 2 3 4

Moisture Barrier Cream** Other Qty ____*1 2 3 4

* If “Other Qty” is completed, you must provide additional medical justification for the higher quantity requested.

Moisture Barrier Lotion** Other Qty ____*1 2 3 4

Protectant Powder** Other Qty ____*

** 1 Unit = One container (bottle, tube, etc.) regardless of size or volume.1 2 3 4

Skin Cleanser** Other Qty ____*1 2 3 4

*** Note to Supplier: If the packaging quantity is not the same as the 100/200/300/400/500 quantity circled, you may round to the nearest size packaging to avoid breaking open a package.

Disposable Wipes (each)*** Other Qty ____*100 200 300 400 500

Disposable Wash Cloths (each)*** Other Qty ____*100 200 300 400 500

NOTE: These supplies are for incontinence treatment only and not for treatment of other areas of the body.

ATTESTATION, SIGNATURE AND DATE OF PHYSICIAN/ PHYSICIAN ASSISTANT/NURSE PRACTITIONERA physician, physician assistant, or nurse practitioner who attests to the medical necessity and quantity of the prescribed items, who knowingly or willfully makes, or causes to be made, any false statement or representation of a material fact in any application for Medicaid benefits or Medicaid payments, may be prosecuted under federal and/or statecriminal laws, and/or may be subject to civil monetary penalties and/or fines. I certify that the medical necessity information is true, accurate and complete to the best of my knowledge. I certify that I have reviewed the services or items requested in this form and that I deem them medically necessary for the patient listed. I understand that any falsification, omission or concealment of material fact may subject me to civil monetary penalties, fines or criminal prosecution.

I hereby certify that I am the ordering physician, physician assistant, or nurse practitioner identified in this form.

_____________________________________________________________ ______________________Signature of Physician / Physician Assistant / Nurse Practitioner Date

Rev. 06/24/15Return to Table of Contents

Download Fillable Form:http://manuals.medicaidalaska.com/docs/dnld/Form_CMN_Incontinence.pdf

Certificate of Medical Necessity for Incontinence Supplies, Page 2 of 2

MEMBER INFORMATION PROVIDER INFORMATION

Member Name: (Last, First, MI)





Phone Number: _______________________ Ext. ___________

SECTION C - REQUESTED SERVICES OR ITEMS Xerox Use Only

Provider Name: _________________________________________________

Address: ______________________________________________________

Provider Medicaid ID: ____________________________________________

Requester Name: _______________________________________________

Phone Number: ________________________ Ext. _______________

Fax Number: ________________________ Ext. _______________

Dates of Need – Start Date: ______________ End Date: _____________

Approved: As requested Modified request

Denied:

Service Authorization No:

________________________________________________

Start Date: ______________ End Date: ______________

Comments:

Authorizing Agent Signature/Date:____________________________________________

Procedure Code Mod Description Qty Charges Authorized Approved

QuantityApprovedAmount

For services/items to be provided on or prior to 9/30/2015 only Yes No1

2

3

4

5

6

7For services/items to be provided on or after 10/1/2015 only

1

2

3

4

5

6

7

SECTION D - SUPPLIER ATTESTATION, SIGNATURE AND DATE

I certify that those services or items listed in this form are those exact services or items ordered and certified as medically necessary by the ordering physician/physician assistant/nurse practitioner specified in this form, and that these exact services or items listed in this form will be supplied to the specified member. A provider who knowingly or willfully makes or causes to be made, a false statement or representation of a material fact in any application for Medicaid benefits or Medicaid payments may be prosecuted under Federal and State criminal laws. A false attestation can result in civil monetary penalties as well as fines, and mayautomatically disqualify the provider as a provider of Medicaid services.

_____________________________________________________________ ______________________Signature of Supplier Date


Download Fillable Form:http://manuals.medicaidalaska.com/docs/dnld/Form_CMN_Incontinence.pdf


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Ostomy Supplies Prescription

RXHMEOS092016

q There is evidence in my patient’s medical record of a surgically created opening to divert urine

and/or fecal contents outside their body.

(Select ICD-10 Code) q Z93.2 q Z43.2 q Z93.3 q Z43.3 q Z93.6 q Z43.6_______________________________________________________________________________________

Ostomy Pouches _____/each monthly q 1 Piece System q 2 Piece System

(Please Select) q Drainable q Closed End I q Clear q Opaque I q Filter q Vent_______________________________________________________________________________________

Wafers _____/monthly (box amounts not valid) q with flange Size of Stoma _______

(Please Select) q Cut to Fit q Precut I q Stomahesive q Durahesive I q Flexible q Solid_______________________________________________________________________________________

Ostomy supplies (box amounts not valid)

q Ostomy belt 1/mo Other Qty ____ qGauze 60/mo (circle size) 4x4 2x2 Other Qty ____

q Barrier rings 10/mo Other Qty ____ qAdhesive Remover 16oz/6 mo Other Qty ____

q Stomahesive paste 4 oz/mo Other Qty ____ qStomahesive Powder 10oz/6mo Other Qty ____

q Appliance cleaner 16 oz/mo Other Qty ____ qAdhesive Spray 4 oz/mo Other Qty ____

q Skin prep/barrier wipes 150/6mo Other Qty ____ qEakin Cohesive Seal 20/mo Other Qty ____

q Tail closure clamps ____/mo


Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________




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Urological Supplies Prescription

RXHMEUS092016

q Medical record supports that patient has a permanent impairment (3 months or greater) of urination. _______________________________________________________________________________________

Catheters

q Intermittent ______/mo French size (select) q 6 q 8 q 10 q 12 q 14 q 16 q 18 q 20 q 22 q 24

q Foley (indwelling)______/mo French size (select) q 6 q 8 q 10 q 12 q 14 q 16 q 18 q 20 q 22 q 24

q External male ______/mo ______mm

q Tip style (select) qStraight qCoude qFunnel_______________________________________________________________________________________

Supplies to be dispensed monthly (box amounts not valid)

q Sterile lubricant pack 1 per catheter change Other Qty:____ qNon sterile lubricant 2oz/mo Other Qty: ____

q 60ml syringe 4/mo Other Qty: ____ qInsertion tray 1 per catheter change Other Qty: ____

q Tape roll ___/mo (select size) q1in. q2in. q3in. (select type) qwaterproof qnon-waterproof

q Sterile H2O 1,000ml bottle_____ qAppliance cleaner 16oz/mo Other Qty: ___________________________________________________________________________________________

q Leg/Abdomen Drainage bag 2/mo Other Qty: ____

q Overnight drainage bag (bedside) 2/mo Other Qty: ____


Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________




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Compression Garment Prescription

RXHMECG092016

Lower Extremity Garments Quantity Ordered ______ Pairs Per Month

q Knee High q Thigh High q Pantyhose q Maternity Pantyhose

q 20-30 mmHg q 30-40 mmHg q 40-50 mmHg_______________________________________________________________________________________

Hand Gauntlets/Gloves Quantity Ordered ______ Per Year

q w/Thumb Stub q w/Finger Stubs q Closed Fingers

q 18-21 mmHg q 23-32 mmHg_______________________________________________________________________________________

Arm Sleeve Quantity Ordered ______ Sleeves Per Year

q Left q Right q Bilateral

q 20-30 mmHg q 30-40 mmHg q 40-50 mmHg

q Shoulder Attachment_______________________________________________________________________________________

q Donning Device


Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________




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Wound Supply Prescription

RXHMEWS092016

Is the wound caused or treated by a surgical procedure? q Yes q No _____ # of wounds

Is debridement of the wound medically necessary? q Yes q No _____ # of wounds

Other type of wound: ___________________________________________________ _____ # of wounds_______________________________________________________________________________________

Daily Supply

Product Needed ______________________________________________________ Size _______________

Primary or Secondary dressing _______________________________________________________________

Daily frequency of change ________________________ Number to be used at one time _____________

Is tape required for this product? q Yes q No

q Tape roll ___/mo (select size) q 1in. q 2in. q 3in. (select type) q waterproof q non-waterproof_______________________________________________________________________________________

Daily Supply





q Tape roll ___/mo (select size) q 1in. q 2in. q 3in. (select type) q waterproof q non-waterproof


Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________


Continues page 2


Wound Supply Prescription Cont.

RXHMEWS092016

Daily Supply






Daily Supply






Daily Supply






Daily Supply





q Tape roll ___/mo (select size) q 1in. q 2in. q 3in. (select type) q waterproof q non-waterproof


Provider Name: ______________________________ Patient’s Name: _____________________________


Open Prescription

RXHMEOP092016

Provider Name: ______________________________

Phone: ____________________________________

Fax: _______________________________________

NPI: _______________________


Equipment or Supplies Prescribed (include any quantities needed monthly, etc.)

Patient’s Name: _____________________________

Date of Birth: _______________________________

Initial Date: _________________________________




Certificate of Medical Necessity, Page 1 of 2

MEMBER INFORMATION PROVIDER INFORMATIONMember Name: (Last, First, MI)





Phone Number: _______________________ Ext. ___________

*Height: _____ (inches) *Weight: ______ (pounds)

Date of Last Visit: ___________________

Prescription Start Date: ________________

Retrospective Review? Yes No

SECTION A - CLINICAL INFORMATION (This section MUST be completed by the attending physician, physician assistant, nurse practitioner, or audiologist.)Diagnosis Code Diagnosis Description

ICD-9

Enter the corresponding ICD-10 diagnosis code and description if requested services/items extend beyond September 30th, 2015.

ICD-10

Estimated Length of Need (# of Months): _______ (99 = Lifetime)

SECTION B - CLINICAL ASSESSMENT OF NEED FOR PRESCRIBED SERVICE(S) OR ITEM(S) AND PLAN Annotate the medical justification, as it pertains to the member’s specific diagnosis, indicating the medical necessity of the requested services or items. Attach any supporting documentation as needed for further justification.(This section may be completed by the attending specialist, including the physician, physician assistant, nurse practitioner, physical therapist, occupational therapist, speech language pathology therapist, registered dietitian, audiologist, or other attending specialist within the scope of his or her specialty.)

PLAN: The plan should list each service or item specifically needed for the treatment of the member. Additional treatment information may be attached to this form.

ATTESTATION, SIGNATURE AND DATE OF PHYSICIAN/ PHYSICIAN ASSISTANT/NURSE PRACTITIONER/ AUDIOLOGIST AND SPECIALIST(Note: Specialist = PT, OT, SLP, RD, MD, NP, PhD, LSW, etc.)A physician, physician assistant, nurse practitioner, audiologist or specialist who attests to the medical necessity of the prescribed items, who knowingly or willfully makes, or causes to be made, any false statement or representation of a material fact in any application for Medicaid benefits or Medicaid payments, may be prosecuted under federal and/or state criminal laws and/or may be subject to civil monetary penalties and/or fines. I certify that the medical necessity information is true, accurate and complete to the best of my knowledge. I certify that I have reviewed the services or items requested in this form and that I deem them medically necessary for the patient listed. I understand that any falsification, omission or concealment of material fact may subject me to civil monetary penalties, fines or criminal prosecution.

This must be signed by the specialist if Section B is completed by someone other than the provider in Section A.

_____________________________________________________________ ______________________Signature of Specialist, Title Date

I hereby certify that I am the ordering physician/physician assistant/nurse practitioner/audiologist identified in this form.

_____________________________________________________________ ______________________Signature of Physician / Physician Assistant / Nurse Practitioner / Audiologist Date


Download Fillable Form:http://manuals.medicaidalaska.com/docs/dnld/Form_CMN.pdf

Certificate of Medical Necessity, Page 2 of 2

MEMBER INFORMATION PROVIDER INFORMATION

Member Name: (Last, First, MI)





Phone Number: _______________________ Ext. ___________

SECTION C - REQUESTED SERVICES OR ITEMS (To Be Completed by DME, P&O, Audiology, or Hearing Aid Providers)

Xerox Use OnlyApproved: As requested Modified request

Denied:

Service Authorization No:

________________________________________________

Start Date: ______________ End Date: ______________

Provider Name: _________________________________________________

Address: ______________________________________________________

Provider Medicaid ID: ____________________________________________

Requester Name: _______________________________________________

Phone Number: ________________________ Ext. _______________

Fax Number: ________________________ Ext. _______________

Dates of Need – Start Date: ______________ End Date: _____________

Comments:

Authorizing Agent Signature/Date:____________________________________________

Procedure Code Mod Description Qty Charges Authorized Approved

QuantityApprovedAmount

For services/items to be provided on or prior to 9/30/2015 only Yes No1

2

3

4

5

6

7For services/items to be provided on or after 10/1/2015 only

1

2

3

4

5

6

7

SECTION D - SUPPLIER ATTESTATION, SIGNATURE AND DATEI certify that those services or items listed in this form are those exact services or items ordered and certified as medically necessary by the ordering physician/physician assistant/nurse practitioner/ audiologist specified in this form, and that these exact services or items listed in this form will be supplied to the specified member. A provider who knowingly or willfully makes, or causes to be made, false statement or representation of a material fact in any application for Medicaid benefits or Medicaid payments may be prosecuted under Federal and State criminal laws. A false attestation can result in civil monetary penalties as well as fines, and may automatically disqualify the provider as a provider of Medicaid services.

_____________________________________________________________ ______________________Signature of Supplier Date


Download Fillable Form:http://manuals.medicaidalaska.com/docs/dnld/Form_CMN.pdf

Letter of Justification

LOJ092016

ENFAMIL ENFACARE W/LIPIL FORMULA EA

DUOCAL UNFLAVORED 14 OZ CN

PEPTAMEN JR W/ PREBIO EA

RESOURCE BREEZE VARIETY EA

BENEPROTEIN POWDER 800 CAL/CAN

WAFER SUR-FIT NATURA 4X4 1 3/4” FLANGE 5/BX

BRIEF GOODNITES BOY SM/MED CS

CALMOSEPTINE OINTMENT TUBE 4OZ EA

ADHESIVE SPRAY RELEASER 1 2/3 OZ

POUCH DRAINABLE 2 PIECE 2-1/4” FLANGE

VITAL 1.5 CAL VANILLA 8 OZ EA

NEOCATE JUNIOR VANILLA WITH PREBIOTICS

LINER TENA NIGHT SUPER CS

LINERS POISE ULTIMATE 33PK

ADHESIVE SPRAY 3.2 OZ EA

PEPTAMEN JR. VANILLA 8 OZ CAN EA

PEPTAMEN 1 CAL 8 OZ UNFLV EA

PROCEL PROTEIN SUPPLEMENT 10 OZ CN EA

BRIEF TRANQUILITY OVERNIGHT SMALL CS

PATIENT CIRCUITS W/PEEP EA

PEPTAMEN JR UNFLAVORED 8.45OZ EA 250 cal/can

PEPTAMEN JR 1.5 EA 375 cal/can

OPTISOURCE HP STRAWBERRY 8OZ EA

PEPTAMEN 1.5 CAL 8 OZ UNFLV EA

MEPILEX SACRUM 9.2 X 9.2 5/BOX

MEPILEX AG 4X4 EA

WIPES NO STING BARRIER FILM EA 25/BX

WAFER SUR-FIT NATURA 4X4 1 3/4” FLANGE 5/BX

BRIEF GOODNITES BOY SM/MED CS

PULL UPS GOODNITES LRG XLRG GIRL 44/CS

IMPACT PEPTIDE 1.5 1000 ML EA 1,500 cal

ADHESIVE SPRAY RELEASER 1 2/3 OZ

POUCH DRAINABLE 2 PIECE 2-1/4” FLANGE

ELECARE JR. VANILLA 14.1 OZ POWDER EA

NEOSURE SIMILAC EXPERT CARE POWDER 13.1 OZ

PEPTAMEN JR. VANILLA W/FIBER 8OZ EA

PEDIASURE PEPTIDE 1.0 VANILLA 8OZ BTL EA

HYDROFERA BLUE BACTERIOSTATIC 4”X4” DRESSING EACH

These items must have a letter of justification from the physician’s office and be discussed with

Geneva Woods personnel prior to approval


Alaska Medicaid Service Authorization Release Form

REVAKHME201416

Medicaid Recipient Name: __________________________________________________________________

Medicaid ID #: ___________________________________________________________________________

Provider to be released: ____________________________________________________________________

Date of service to be released: __________________________

I am hereby requesting that Prior Authorizations for the following services to be released to Geneva Woods

Health Care Services: _________________________________

Please fax all relevant documentation, including but not limited to CMNs, Prescriptions, Prior Authorizations, Progress Notes, and last delivery ticket.

Client/Guardian Signature: ___________________________________________ Date: _________________

Printed Name and relationship (if applicable): ___________________________________________________

3674 E Country Field CirWasilla, AK 99654907.376.8200 Phone866.460.8792 Fax

Confidentiality Notice: Information contained in this facsimile or fax may contain private and confidential material, protected health information and/or trade secret materials for the sole use of the individual named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying or distribution of the information or the taking of any action with regard to the contents of this transmission is strictly prohibited. Please notify us immediately by telephone at 1 (800) 478-0005 so that we can arrange for the return of this material at no cost to you. For more information on HIPAA compliance and safeguards within faxes, please visit: http://www.hhs.gov/hipaafaq/providers/smaller/482.html

501 W International Airport Rd, Ste 1AAnchorage, AK 99518907.565.6100 Phone866.565.6112 Fax

44604 Sterling Hwy, Ste C Soldotna, AK 99699907.262.2424 Phone866.628.6832 Fax


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Interactive Durable Medical Equipment & Supply ......Interactive Durable Medical Equipment & Supply Documentation Guidelines Confidentiality Notice: Information contained on this site