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SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES

MEDICAID CERTIFICATE OF MEDICAL NECESSITY FORM

FOR EQUIPMENT/SUPPLIES

SECTION A: MUST BE COMPLETED BY DME PROVIDER

(1) Recipient’s name: ________________________________________________ Medicaid # (10 digits): _____________________________________

(2) DOB: ___/___/_____: Sex: ___ HT: _________ (in); WT: _____________ Date of Service: _____/_____/_________________________________

(3) Provider’s name: ____________________________________________ Provider’s DME # __________NPI#________________________________

(4) Street address: _______________________________ City: ____________________ State: ____ Zip: _______Local telephone #: ______________

(5) Provider’s signature: _______________________________________________Date: ____________________________________________________

(6)

LIST ALL PROCEDURE CODES THAT ARE ORDERED BY THE TREATING/ORDERING PHYSICIAN FOR EQUIPMENT/SUPPLIES:

_________________________________________________________________________________________________________________________________________

NOTE: FOR ALL PROCEDURE CODES THAT ARE COVERED, BUT DO NOT HAVE AN ESTABLISHED PRICE, YOU MUST INCLUDE

MANUFACTURER PRICE LIST.

SECTION B: ALL FIELDS IF APPLICABLE MUST BE COMPLETED BY TREATING/ORDERING PHYSICIAN

(7) Diagnosis codes (ICD) __________ Description(s):_____________________________________________________________________________

__________

____________________________________________________________________________

__________

____________________________________________________________________________

(8) Indicate patient’s ambulatory status while performing activities of daily living: ___Non-ambulatory ___Ambulatory, without assistance

___Ambulatory with the aid of a walker or cane, ____Ambulatory, with other assistance as described

_____________________________________________________________________________________________________________________________

Does the patient have decubitus ulcers? ___ Yes ___ No.

If yes, circle stage(s): I, II, III, or IV. Indicate the wound size(s): _________________

Please describe how this equipment / supply is medically necessary, the benefits to the recipient and how long will it take for the benefit to be

evident:

_____________________________________________________________________________________________________________________________

(9) For supplies, please indicate the dressing change required per day, week, month, etc.

_____________________________________________________________________________________________________________________________

Is additional information attached on separate sheet? ______Yes ______No (If “yes,” enter recipient’s name & I.D. Medicaid number on

attachment

(10) Please indicate the date that the patient was seen for the equipment/supplies prescribed: _______________

(11) Please indicate the prescription date: __________________

(

) Duration of need (maximum of 12 months): ____________________________

(Please indicate duration by months, not to exceed 12).

I certify that I am the treating/ordering physician identified in Section B of this form. Any statement attached hereto has been reviewed and signed by me. I certify

that the medical necessity information is true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission or concealment

of material fact may subject me to civil or criminal liability. Additionally, I certify that the requested equipment/supplies are appropriate for the patient.

(13)

PHYSICIAN’S NAME :___________________________________________________________

PHYSICIAN’S NPI # :___________________

PHYSICIAN’S SIGNATURE __________________________________DATE___/___/___ (SIGNATURE AND DATE STAMPS ARE NOT ACCEPTABLE)

PLEASE REFER TO THE MEDICAID CMN POLICY IN THE DME MEDICAID PROVIDER MANUAL.

DME 001 - Dated 09/01/15