Certificate of Medical Necessity (CMN) form for supplies and medical equipment
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Template form and instructions for documenting medical necessity when ordering supplies or durable medical equipment (DME) that do not have a product-specific CMN. Governs suppliers and ordering physicians completing certification information for Blue Cross Blue Shield - Kansas members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Physician signature stamps are not acceptable. The certification requires the physician’s actual handwritten signature in Section 3; stamped signatures or date stamps do not meet the form’s signature requirement and may render the attestation invalid.
Coding Requirements
| ICD-10 | Diagnosis codes (separate with a comma) |
Provider Actions & Submission Requirements
Submission and signature
Complete and signed CMN form must be submitted with orders for supplies or medical equipment when a product-specific CMN is not available. Include the estimated length of need, ICD-10 diagnosis codes, and a brief description of the prescribed item. If Section 1B is left blank, the physician must complete it before submission. Incomplete or missing CMNs may delay processing.
- Attach a completed CMN with all required provider and supplier information when no product-specific CMN exists.
- Include ICD-10 diagnosis codes (comma-separated) and estimated length of need (1–99 months; 99 = lifetime).
- Provide brief description of supplies/medical equipment and patient physical limitations; attach additional pages if needed.
Required form fields
Complete Section 1B with provider and supplier demographics: physician and supplier names, contact information, NPI/ID numbers, addresses, patient height/weight, initial/revised certification dates, and estimated length of need. Include diagnosis codes and the brief clinical rationale needed to support medical necessity.
- Physician and supplier full names, phone numbers, ID/NPI numbers, and addresses (including city, state, ZIP +4, county).
- Patient height and weight fields when applicable.
- Initial Certification Date and Revised Certification Date fields must be completed.
- Briefly list specific patient physical limitations/conditions pertinent to the request; attach additional sheet if needed.
Signature requirements
Physician signature is required on Section 3. Signature and date stamps are not acceptable; unsigned or stamped forms may result in denial of certification. The physician must attest that the medical necessity information is true, accurate, and complete.
- Physician must sign and date Section 3; signature stamps are unacceptable.
- The attestation: 'I certify that I am the physician identified in section 1C of this form. I certify that the medical necessity information is true, accurate and complete, to the best of my knowledge.'
- Unsigned or stamped forms may trigger denial or delay.
Background
This document is a general Certificate of Medical Necessity (CMN) used to document medical necessity for durable medical equipment and supplies when no product-specific CMN exists. It captures supplier and patient identifiers, ICD-10 diagnosis code(s), an estimated length of need (months) entry, brief descriptions of patient limitations and the prescribed equipment, and a physician attestation in Section 3.
Definitions
Medical Necessity
Documentation-based medical necessity
Medical necessity is documented via completion of the form fields and physician attestation.
Physician signature stamps are not acceptable.
Rental & Purchase Rules
| Rule | Details |
|---|---|
| Rental & purchase rules | No specific rental or purchase rules provided on this generic CMN form. |
| Applicability | Applies to supplies and medical equipment for which no product‑specific CMN exists; the form captures supplier and patient information but does not define rental vs. purchase billing rules. |
| Estimated length of need | Form includes an 'Estimated length of need' field allowing 1–99 months (99 = Lifetime); no rental/purchase thresholds are specified. |
| Physician signature | Physician attestation and original handwritten signature required in Section 3; signature stamps are not acceptable and may invalidate certification, but no purchase/rental impacts are detailed. |
Replacement
Documentation Requirements
Include completed, signed CMN with order
The completed CMN submitted with the DME/supply order must include supplier and patient identifying information, ICD‑10 diagnosis codes, a description of the patient’s pertinent physical limitations, a description of the equipment or supplies prescribed, the estimated length of need, and the physician’s attestation with an actual signature in Section 3.
- Supplier and patient identifying information (Section 1B).
- ICD‑10 diagnosis codes.
- Description of patient physical limitations relevant to the request.
- Description of the supply or medical equipment prescribed.
- Estimated length of need (1–99 months, where 99 = lifetime).
- Physician attestation and handwritten signature in Section 3.
Not Covered / Denial Risks
Forms bearing physician signature stamps rather than an original handwritten signature are not acceptable and may be considered invalid. Section 3 expressly states: “Physician's Signature (Signature and date stamps are not acceptable),” and the physician’s handwritten signature and date are required to validate the attestation.
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