Form Hcfa 845 - Certificate Of Medical Necessity - U.s. Department Of Health & Human Services Page 2

SECTION A:

(May be completed by the supplier)

CERTIFICATION

If this is an initial certification for this patient, indicate this by placing date (MM/DD/YY) needed initially in the space marked

TYPE/DATE:

"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 also 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 also 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

Indicate the patient's name, permanent legal address, telephone number and his/her health insurance claim number (HICN)

INFORMATION:

as it appears on his/her Medicare card and on the claim form.

SUPPLIER

Indicate the name of your company (supplier name), address and telephone number along with the Medicare Supplier

INFORMATION:

Number assigned to you by the National Supplier Clearinghouse (NSC).

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.

HCPCS CODES:

List all HCPCS procedure codes for items ordered that require a CMN. Procedure codes that do not require certification

should not be listed on the CMN.

PATIENT DOB, HEIGHT,

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

WEIGHT AND SEX:

PHYSICIAN NAME,

Indicate the physician's name and complete mailing address.

ADDRESS:

UPIN:

Accurately indicate the ordering physician's Unique Physician Identification Number (UPIN).

PHYSICIAN'S

Indicate the telephone number where the physician can be contacted (preferably where records would be accessible

TELEPHONE NO:

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 ordering physician.)

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 physician expects that the patient will require the item for the duration of

his/her life, then enter 99.

DIAGNOSIS CODES:

In the first space, list the ICD9 code that represents the primary reason for ordering this item. List any additional ICD9 codes

that would further describe the medical need for the item (up to 3 codes).

QUESTION SECTION:

This section is used to gather clinical information to determine medical necessity. Answer each question which applies to the

items ordered, circling "Y" for yes, "N" for no, "D" for does not apply, a number if this is offered as an answer option, or fill in

the blank if other information is requested.

NAME OF PERSON

If a clinical professional other than the ordering physician (e.g., home health nurse, physical therapist, dietician)

ANSWERING SECTION B

QUESTIONS:

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

Supplier gives (1) a narrative description of the item(s) ordered, as well as all options, accessories, supplies and drugs;

(2)

DESCRIPTION OF

the supplier's charge for each item, option, accessory, supply and drug; and (3) the Medicare fee schedule allowance for

EQUIPMENT & COST:

each item/option/accessory/supply/drug, if applicable.

SECTION D:

(To be completed by the physician)

PHYSICIAN

The physician's signature certifies (1) the CMN which he/she is reviewing includes Sections A, B, C and D; (2) the answers in

ATTESTATION:

Section B are correct; and (3) the self-identifying information in Section A is correct.

PHYSICIAN SIGNATURE

After completion and/or review by the physician of Sections A, B and C, the physician must sign and date the CMN in Section

AND DATE:

D, verifying the Attestation appearing in this Section. The physician's signature also certifies the items ordered are medically

necessary for this patient. Signature and date stamps are not acceptable.

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 0938-0679. The time required to complete this information collection is estimated to average 15 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:

HCFA, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.