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INSTRUCTIONS FOR COMPLETING THE MEDICAID CERTIFICATE OF MEDICAL NECESSITY FOR EQUIPMENT/SUPPLIES

SECTION A: MUST BE COMPLETED BY DME PROVIDER

RECIPIENT’S NAME AND

MEDICAID #:

Indicate the patient’s name and his/her Medicaid # (10 digits).

PATIENT DOB, SEX, HEIGHT, WEIGHT: Indicate patient’s date of birth (MM/DD/YY) and sex (male or female); height in inches and weight in

pounds.

DATE OF SERVICE:

Indicate the date of service (DOS). The date of service must be the same as the delivery date.

PROVIDER‘S NAME, DME #

AND NPI#:

Indicate the name of the DME company (Provider name), Provider’s DME# and NPI#.

PROVIDER’S PHYSICAL ADDRESS

AND TELEPHONE NUMBER:

Indicate the provider’s physical address (provider’s location) and telephone number.

PROVIDER SIGNATURE AND DATE:

Signature of DME provider representative and date.

HCPCS CODES:

List all HCPCS procedure codes for items ordered by the treating/ordering physician.

Note: For all procedure codes that are covered, but do not have an established price, you must include

manufacturer price list.

SECTION B: MUST BE COMPLETED BY TREATING/ORDERING PHYSICIAN:

DIAGNOSIS CODES:

In the first field, list the ICD diagnosis code(s) that represent(s) the primary reason(s) for ordering

this item. In the second field, list the description(s) for each ICD diagnosis code(s).

QUESTION SECTION:

These fields are used to gather clinical information to help Medicaid determine the medical necessity

for the item(s) being ordered. Answer each question which applies to the items ordered.

DATE PATIENT WAS SEEN FOR

EQUIPMENT/SUPPLIES PRESCRIBED:

Indicate the date patient was seen by the treating/ordering physician, nurse practitioner or physician

assistant for the equipment/supplies prescribed. The treating/ordering physician, nurse practitioner

or physician assistant must examine the beneficiary within 60 days before prescribing equipment

and/or supplies

PRESCRIPTION DATE:

Indicate the prescription date. The prescription date must be within 60 days of the date of

treating/ordering physician’s signature and the date the beneficiary was seen by the physician, nurse

practitioner, or physician assistant. All MCMNs that are not signed within this time frame will be

returned (if submitted with a PA) or rejected (if attached to a claim) and the MCMN will be deemed

invalid.

EST. LENGTH OF NEED:

Indicate the estimated length of need (the length of time the physician expects the patient to require

use of the order item) by filling in the appropriate number of months, up to 12 months. An MCMN

can be valid up to a maximum of 12 months from the date the patient was seen for the

equipment/supplies prescribed.

PHYSICIAN ATTESTATION:

The physician signature certifies (1) the CMN which he/she is reviewing includes Sections A and B;

(2) answers in Section B are correct and the self-identifying information in Section A is correct.

PHYSICIAN SIGNATURE AND

DATE:

After completion and/or review by the physician of Sections A and B the physician’s must sign and

date the CMN in Section B, verifying the Attestation appearing in this Section. The physician’s

signature also certifies the item(s) order is medically necessary for this patient.

DME 001 – Dated 09/01/15

Medicaid Certificate Of Medical Necessity Form - South Carolina Department Of Health Page 2

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