Currentblue cross blue shield - alabamaPolicy N/A

Durable Medical Equipment Certification Form (DME)

A payer DME certification form that documents patient, clinical and supplier information required to certify rental or purchase of durable medical equipment (including oxygen, IPPB, glucometer, CPAP/BIPAP, beds, mobility aids). Applies to providers and suppliers submitting DME claims to Blue Cross Blue Shield - Alabama.

Policy Summary

Payerblue cross blue shield - alabama

PolicyDurable Medical Equipment Certification Form (DME)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and sign the certification form, list requested HCPCS code(s) and rental period (certification length cannot exceed 12 months), and retain PaO2/oximetry results for oxygen orders.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12max general rental

6max oxygen/IPPB

PRV20098-2305form id

205-220-9560fax

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

General medical necessity

Coverage is supported when the prescribing physician documents medical necessity and completes the relevant sections for the equipment type; certification length limits apply.

General DME certification: Physician must certify equipment is part of active treatment, reasonable and necessary, complete patient and supplier identification fields, provide requested HCPCS code(s) and rental period, and sign and date the form.

Certification length for general DME rental period cannot exceed 12 months; supplier must list HCPCS code(s) on the form.

Oxygen/respiratory therapy

Oxygen-specific criteria

Oxygen therapy: Provider must supply and retain objective oxygenation data (PaO2 or oximetry results) and document where and under what condition the test was performed; document hours per day of use, type and delivery method, flow rate, and prior treatments tried without success; notify the carrier in writing when oxygen needs change.PaO2 or oximetry values (numeric threshold not specified on form)

Certification length cannot exceed six months for the oxygen section.

IPPB

IPPB-specific criteria

IPPB use: Document current pulmonary function study results (including forced vital capacity before and after bronchodilator and predicted VC), indicate IPPB frequency of use, select intended therapeutic purposes (e.g., deliver aerosolized medications, facilitate secretion clearance, correct or prevent atelectasis, decrease work of breathing), and confirm whether the patient can use a hand-held nebulizer or compressor.

Certification length cannot exceed six months for the IPPB section.

Glucometer

Glucometer criteria

Home glucose monitor: Document that the patient is insulin-dependent, record average daily insulin dose, insulin type, number of daily injections, presence of widely fluctuating blood sugars or frequent insulin reactions, necessity for frequent glucose checks, vision impairment requiring a special monitoring system, and the patient's capability to be trained to use a home blood glucose monitor.

Coding and Codes to Supply

HCPCS codes (supplier-entered)HCPCS

Requested HCPCS code(s)

Field for supplier to list HCPCS codes for requested equipment

Oxygenation thresholds (PaO2 / oximetry)

Form field requestedPaO2 (blood gas) level or oximetry level must be provided and retained in provider files.

Numeric threshold on formNo numeric PaO2 or oximetry threshold is specified on the form (provider supplies measured value).

Test timing/context optionsForm documents whether measurement was taken at rest, during activity (e.g., exercise), or while sleeping.

Oxygen status at time of testForm asks whether patient was on room air or oxygen at time of the blood gas/oximetry study.

Required Provider Actions and Documentation

Documentation Required

HCPCS Codes and Certification Period

Provider must list all requested HCPCS code(s) and specify the certification rental period (first and last day). The certification period cannot exceed 12 months.

Requested HCPCS code(s) must be entered on the form (see line 11).
Enter Rental Period (First Day and Last Day). Certification length CANNOT exceed 12 months.

Documentation Required

Prior Treatment Documentation for Oxygen

Retain and provide prior treatment documentation showing therapies tried without success before initiating oxygen therapy. Complete the prior treatments section with dates and details of medications, bronchodilators, physical therapy (percussors, breathing exercises) and any other interventions attempted.

Document treatments tried WITHOUT SUCCESS prior to oxygen (section lists bronchodilators, medications with name/dosage, physical therapy, percussors, breathing exercises, other treatments).
Include BEGIN and ENDED dates (MM-DD-YYYY) for each treatment.

Documentation Required

Required Form Fields and Supporting Tests

Complete all required form fields and include supporting test results. Ensure patient identification, diagnosis, estimated months equipment needed (do NOT enter 'INDEFINITE'), mobility status, supplier information, and hours/flow rates for oxygen are documented.

Patient identification: name, date last seen by doctor, subscriber number, diagnosis, prognosis, estimated number of months equipment needed (be specific).
Mobility status: bed confined, room confined, wheelchair confined, ambulatory status and assistance required (complete applicable sub-items).
Supplier information: supplier name, address, provider number, requested HCPCS code(s).
Oxygen specifics: type of unit (portable/stationary/concentrator/liquid/gaseous), hours per day (portable and non-portable), flow rate (L/min), delivery method (nasal cannula, mask), and whether oxygen was used at rest, during activity, or sleep.

Documentation Required

Oxygen Documentation Requirement (Blood Gas / Oximetry)

Provide and retain blood gas study (PaO2) or oximetry results and indicate where the test was performed. Notify the carrier in writing whenever the patient's condition or oxygen needs change.

Record report date, PaO2 (mm Hg) or oximetry level, and testing location (home, doctor's office, nursing home, independent lab, hospital, ASC).
Indicate patient condition during test (at rest, during activity/exercise, while sleeping) and whether patient was on room air or oxygen at time of test.
Carrier must be notified in writing if patient's condition or oxygen needs change.

Prior Authorization

Signature and Certification Requirement

The prescribing physician must complete, sign, and date the form. Stamped signatures are not acceptable. The physician certifies active treatment and that equipment is reasonable and necessary. Misrepresentation or falsification may constitute fraud.

Form must be completed, signed (handwritten) and dated by the prescribing physician (section 34–35).
Stamped signature is NOT acceptable.
Physician statement must certify active treatment, medical necessity, and accuracy of form entries. Misrepresentation/falsification may be subject to legal action.

Background

This certification form collects the prescribing physician’s clinical attestation and patient-treatment information needed to establish medical necessity for durable medical equipment. The form requires the physician to confirm active treatment, that the equipment is reasonable and necessary, to supply provider and patient identification details, and to sign and date the attestation so the carrier can adjudicate the DME claim.

Definitions and Key Fields

Objective oxygenation data required for oxygen orders

Required objective data for oxygen ordersPaO2 (blood gas) or oximetry results must be provided and retained in provider files.

HCPCS codes required on formSupplier must list the requested HCPCS code(s) in the designated field on the certification form.

Certification/rental periodProvider must specify the rental period; general certification length cannot exceed 12 months (form field captures first and last day).

Supplier identification fieldsForm requires supplier name, address, phone, and provider number to be completed by the supplier.

Billing codes that must be provided by supplier on certification

Field to be completed by supplierRequested HCPCS code(s) — supplier must enter the specific HCPCS code(s) for the equipment being certified.

Supplier contact informationSupplier name, street address, city, state, ZIP code, and phone number must be completed on the form.

Item-Specific Medical Necessity

Beds and repositioning equipment

Bed/electric bed: Document the specific bed type requested and whether the patient is able to operate electric bed controls; indicate if the patient's condition requires frequent position changes not feasible in an ordinary bed, and whether the patient has or is susceptible to decubitus ulcers.

Complete the related bed-specific question numbers on the form (e.g., ability to work controls, need for frequent repositioning, presence/risk of decubitus ulcers).

Rental and Purchase Rules

Equipment	Certification / Rental Period Limit	Notes / Required Provider Actions
General DME (all items covered by the form)	Certification length cannot exceed 12 months (rental period section on form)	Provider must complete patient and supplier fields, list requested HCPCS code(s), enter rental period (first and last day), and supply estimated months equipment needed; physician must sign the form.
Oxygen (stationary, portable, concentrator, liquid/gaseous)	Certification length for oxygen section: cannot exceed 6 months	Provider must supply objective oxygenation data (PaO2 or oximetry) and document hours/day of use, flow rate/delivery method, prior treatments tried; retain blood gas/oximetry results in patient files and notify carrier in writing when oxygen needs change.
IPPB	Certification length for IPPB section: cannot exceed 6 months	Document current pulmonary function study results (FVC before/after bronchodilator, predicted VC), frequency of use, indications for IPPB (select applicable therapeutic purposes), and whether patient can use a hand‑held nebulizer or compressor.

Documentation Requirements

Documentation Required

Keep PaO2/oximetry results on file; physician handwritten signature required; notify carrier of changes

Maintain PaO2/oximetry results in the medical record and ensure the prescribing physician's handwritten signature appears on the form; do NOT use a stamped signature. Notify the carrier in writing when oxygen needs or the patient's condition changes.

Store blood gas (PaO2) or oximetry results with the patient's records (include where and when test was performed and conditions during testing).
Ensure the attending physician signs the certification by hand on the signature line; stamped signatures are explicitly not acceptable.
Send written notice to the carrier for any change in oxygen needs or patient condition.

Policy Summary

Payerblue cross blue shield - alabama

PolicyDurable Medical Equipment Certification Form (DME)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and sign the certification form, list requested HCPCS code(s) and rental period (certification length cannot exceed 12 months), and retain PaO2/oximetry results for oxygen orders.

SourceLink

On This Page

OpenPayer

Durable Medical Equipment Certification Form (DME)

Coverage Criteria

Coding and Codes to Supply

Required Provider Actions and Documentation

Background

Definitions and Key Fields

Item-Specific Medical Necessity

Rental and Purchase Rules

Documentation Requirements

Not Covered / Exclusions