Durable Medical Equipment (DME) Certification/Request Form
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This supplier-attested certification form is used to request, certify, and document durable medical equipment and related services for Alaska Medicaid members; it records member, prescriber, supplier, equipment, and service details and requires supplier attestation.
No material clinical or coverage changes in this revision.
Form Completion and Coverage Criteria
Form completion criteria
Form fields that must be completed to certify equipment and request services; completion supports authorization/coverage processes.
ALL of the following
- Member Name completed
- Member Medicaid ID completed
- Contact Name, Mailing Address, City/State/Zip, Contact Phone Number completed
ALL of the following
- Prescriber Name completed
- Prescriber NPI completed
- Supplier Name completed
- Supplier Medicaid ID completed
ALL of the following
- Certification Type selected (Initial, Revised, or Renewal)
- Requested Start Date provided
- End Date provided
ALL of the following
- HCPCS code entered
- Modifier(s) entered (if applicable)
- Description entered
- Quantity entered
- Charge entered
ALL of the following
- Stationary or Portable: Stationary equipment: Model and Manufacturer provided
- Stationary or Portable: Portable equipment: Model and Manufacturer provided
- Home-fill system: Model and Manufacturer provided
ALL of the following
- Total number of batteries dispensed recorded
- Life per battery (at 2 LPM) recorded
- Portable function note: If portable concentrator will serve as stationary, checkbox indicating single piece of equipment dispensed is marked
ALL of the following
- Supplier attestation text acknowledged
- Signature of Requestor provided (wet or electronic)
- Date of signature provided
HCPCS and Equipment Coding Details
| (row 1) | HCPCS Code — Description (Qty, Charge) |
| (row 2) | HCPCS Code — Description (Qty, Charge) |
| (row 3) | HCPCS Code — Description (Qty, Charge) |
| (row 4) | HCPCS Code — Description (Qty, Charge) |
| MOD | Modifier field (up to two MOD columns provided) |
Certification, Submission, and Provider Responsibilities
DME certification form — complete and submit Sections A–D
Complete Sections A–D of the DME Certification form and submit it with all required member, prescriber, supplier, equipment, and service details. Ensure Section B lists HCPCS codes, modifiers, descriptions, quantities, charges, and requested start and end dates; Section C includes model and manufacturer for stationary/portable/home‑fill equipment and total number of batteries with life per battery; and Section D contains the supplier attestation with a wet or electronic signature.
- Section A: member name, Medicaid ID, prescriber name and NPI, supplier name and Medicaid ID, contact information (chunk 0).
- Section B: requested start and end dates; HCPCS code rows with modifiers, description, quantity, and charge (chunk 1).
- Section C: stationary/portable/home‑fill model and manufacturer; total number of batteries dispensed and life per battery (chunk 2).
- Section D: supplier attestation statement and signature (wet or electronic) with date (chunk 3).
Supplier Attestation and Equipment Details
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