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 TYPE/ |
DATE: |
marked “INITIAL.” If this is a revised certification (to be completed when the physician changes the order, based on the |
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patient’s changing clinical needs), indicate the initial date needed in the space marked “INITIAL,” and indicate the |
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recertification date in the space marked “REVISED.” If this is a recertification, indicate the initial date needed in the |
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space marked “INITIAL,” and indicate the recertification date in the space marked “RECERTIFICATION.” Whether |
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submitting a REVISED or a RECERTIFIED CMN, be sure to always furnish the INITIAL date as well as the REVISED or |
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RECERTIFICATION date. |
PATIENT |
Indicate the patient’s name, permanent legal address, telephone number and his/her Medicare ID as it appears on his/her |
INFORMATION: |
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) or applicable National Provider Identifier (NPI). If |
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using the NPI Number, indicate this by using the qualifier XX followed by the 10-digit number. If using a legacy number, |
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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 |
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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 |
List all procedure codes for items ordered. Procedure codes that do not require certification should not be listed |
PROCEDURE CODE(S): |
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: |
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PHYSICIAN NAME, |
Indicate the PHYSICIAN’S name and complete mailing address. |
ADDRESS: |
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PHYSICIAN |
Accurately indicate the treating physician’s Unique Physician Identification Number (UPIN) or applicable National |
INFORMATION: |
Provider Identifier (NPI). If using the NPI Number, indicate this by using the qualifier XX followed by the 10-digit number. |
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If using UPIN number, use the qualifier 1G followed by the 6-digit number. (For example. 1Gxxxxxx) |
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 |
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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 |
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item) by filling in the appropriate number of months. If the patient will require the item for the duration of his/her life, |
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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 |
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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) |
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being ordered. Answer each question which applies to the items ordered, checking “Y” for yes, “N” for no, or “D” for |
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does not apply. |
NAME OF PERSON |
If a clinical professional other than the treating physician (e.g., home health nurse, physical therapist, dietician) or a |
ANSWERING SECTION B |
physician employee answers the questions of Section B, he/she must print his/her name, give his/her professional title |
QUESTIONS: |
and the name of his/her employer where indicated. If the physician is answering the questions, this space may be |
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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; |
DESCRIPTION OF |
(2) the supplier’s charge for each item(s), options, accessories, supplies and drugs; and (3) the Medicare fee schedule |
EQUIPMENT & COST: |
allowance for each item(s), options, accessories, supplies and drugs, 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 |
ATTESTATION: |
answers in 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’s must sign and date the CMN in |
AND DATE: |
Section D, verifying the Attestation appearing in this Section. The physician’s signature also certifies the items ordered |
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are medically necessary for this patient. |