Durable Medical Equipment Certification Form (DME)
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria
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.
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
Certification length cannot exceed six months for the oxygen section.
IPPB
IPPB-specific criteria
Certification length cannot exceed six months for the IPPB section.
Glucometer
Glucometer criteria
The certification form must be completed, dated, and bear the attending physician's handwritten signature. A stamped signature is NOT acceptable. Failure to provide a valid handwritten signature may result in denial of the request and could be treated as misrepresentation or falsification.
The physician must attest that the prescribed equipment is part of the patient’s present course of treatment and is not prescribed as convenience equipment. Items documented as prescribed for convenience are explicitly not considered reasonable and necessary and therefore will not be certified.
Coding and Codes to Supply
| Requested HCPCS code(s) | Field for supplier to list HCPCS codes for requested equipment |
Required Provider Actions and Documentation
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.
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.
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.
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.
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
Item-Specific Medical Necessity
Beds and repositioning equipment
Beds and repositioning equipment
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
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.
Not Covered / Exclusions
NOT COVERED: Equipment that is prescribed solely for convenience is not considered reasonable and necessary and will not be certified. In addition, forms submitted with a physician’s stamped signature in place of a handwritten signature are unacceptable and may lead to denial or other adverse action.
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