The Health Insurance Continuity of Coverage Form, HCFA 841 is a document that provides information about an insurance policy. The form must be completed by the insurance company and submitted to the Centers for Medicare and Medicaid Services (CMS). The HCFA 841 is used to determine whether or not a policy is considered creditable coverage under the Affordable Care Act (ACA). Creditable coverage means that an individual's health insurance meets certain standards set by the ACA, and therefore does not need to enroll in a health plan through the Marketplace. Completing and submitting the HCFA 841 is important for individuals who are considering enrolling in a health plan through the Marketplace.
| Question | Answer |
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| Form Name | Form Hcfa 841 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | va form for a hospital bed, hospital bed medicare necessity form maryland, CMN, Washington |
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES |
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FORM APPROVED |
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HEALTH CARE FINANCING ADMINISTRATION |
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OMB NO. |
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CERTIFICATE OF MEDICAL NECESSITY |
DMERC 01.02A |
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HOSPITAL BEDS |
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SECTION A |
Certification Type/Date: |
INITIAL ___/___/___ REVISED ___/___/___ |
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PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER
(__ __ __) __ __ __ - __ __ __ __ HICN ____________________________
PLACE OF SERVICE ________ |
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HCPCS CODE |
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NAME and ADDRESS of FACILITY if applicable (See |
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Reverse) |
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SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER
(__ __ __) __ __ __ - __ __ __ __ NSC # __________________________________
PT DOB ____/____/____; Sex ____ (M/F) ; HT.______(in.) ; WT._____(lbs.)
PHYSICIAN NAME, ADDRESS (Printed or Typed)
PHYSICIAN'S UPIN: ______________________________
PHYSICIAN'S TELEPHONE #: (__ __ __) __ __ __- __ __ __ __
SECTION B |
Information in this Section May Not Be Completed by the Supplier of the Items/Supplies. |
EST. LENGTH OF NEED (# OF MONTHS): ______
DIAGNOSIS CODES
ANSWERS
Y N D
Y N D
Y N D
ANSWER QUESTIONS 1, AND
(Circle Y for Yes, N for No, or D for Does Not Apply)
QUESTION 2 RESERVED FOR OTHER OR FUTURE USE.
1.Does the patient require positioning of the body in ways not feasible with an ordinary bed due to a medical condition which is expected to last at least one month?
3.Does the patient require, for the alleviation of pain, positioning of the body in ways not feasible with an ordinary bed?
4.Does the patient require the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or aspiration?
Y N D
Y N D
5.Does the patient require traction which can only be attached to a hospital bed?
6.Does the patient require a bed height different than a fixed height hospital bed to permit transfers to c hair, wheelchair, or standing position?
Y N D
7.Does the patient require frequent changes in body position and/or have an immediate need for a change in body position?
NAME 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) Supplier's charge; and (3) Medicare Fee Schedule Allowance for each item, accessory, and option. (See Instructions On Back)
SECTION DPhysician Attestation and Signature/Date
I certify that I am the 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)
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 |
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changing clinical needs), indicate the initial date needed in the space marked "INITIAL," and also indicate the recertification |
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date in the space marked "REVISED." If this is a recertification, indicate the initial date needed in the space marked |
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"INITIAL," and also indicate the recertification date in the space marked "RECERTIFICATION." Whether submitting a |
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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 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 |
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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 |
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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: |
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PHYSICIAN NAME, |
Indicate the physician's name and complete mailing address. |
ADDRESS: |
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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 |
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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) |
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by filling in the appropriate number of months. If the physician expects that the patient will require the item for the duration of |
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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 |
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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 |
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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 |
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the blank if other information is requested. |
NAME OF PERSON ANSWERING SECTION B QUESTIONS:
If a clinical professional other than the ordering 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 |
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 |
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 |
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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