Currentblue cross blue shield - kansasPolicy N/A

Certificate of Medical Necessity (CMN) form for supplies and medical equipment

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.

Policy Summary

Payerblue cross blue shield - kansas

PolicyCertificate of Medical Necessity (CMN) form for supplies and medical equipment

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed and signed CMN (physician must hand-sign Section 3; signature stamps are not acceptable) with orders for supplies/DME lacking a product-specific CMN.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Sections 1B & 3major form sections present

1-99Estimated length of need field range

ICD-10Diagnosis code system required

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.

Policy Summary

Payerblue cross blue shield - kansas

PolicyCertificate of Medical Necessity (CMN) form for supplies and medical equipment

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed and signed CMN (physician must hand-sign Section 3; signature stamps are not acceptable) with orders for supplies/DME lacking a product-specific CMN.

SourceLink

On This Page

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Provider Actions & Submission Requirements

Documentation Required

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.

Documentation Required

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.

Denial Risk

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.

Medical Necessity

Documentation-based medical necessity

Medical necessity is documented via completion of the form fields and physician attestation.

Form completion and attestation: Sections requiring supplier/patient details, ICD-10 diagnosis, estimated length of need, description of limitations, and description of prescribed equipment must be completed AND physician attestation with handwritten signature in Section 3 must be provided.

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.

Documentation Requirements

Documentation Required

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.

OpenPayer

Certificate of Medical Necessity (CMN) form for supplies and medical equipment

Coverage Criteria

Coding Requirements

Provider Actions & Submission Requirements

Background

Definitions

Medical Necessity

Rental & Purchase Rules

Replacement

Documentation Requirements

Not Covered / Denial Risks