Durable Medical Equipment (DME) certification form
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This document is a DME certification/recertification form governing physician attestation and supplier requests for durable medical equipment, oxygen, IPPB, glucometers, and related devices for Blue Cross Blue Shield - Minnesota members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Clinical Requirements
Form completion and equipment-specific clinical data
Coverage is supported when the prescribing physician completes the form providing required clinical details and attests equipment is reasonable and necessary.
See form fields in chunk 1 and certification period in chunk 1
See chunks 4 and 23
See chunk 5
See chunk 6
The form requires the prescribing physician to certify that the equipment is "reasonable and necessary" and is not prescribed as convenience equipment. This attestation is a mandatory element of the certification and supports adjudication of the DME claim.
The form contains a clear notice that it "must be completed, signed and dated by the prescribing physician to accurately adjudicate the DME Claim." Incomplete, unsigned, or uncertified forms may jeopardize adjudication or lead to denial of the request.
Requested Codes and Clinical Data for Coding
| Requested HCPCS code(s) | Place on form — supplier must list requested HCPCS code(s) |
Supplier and Prescriber Actions Required
HCPCS and Certification Period
Supplier must record the requested HCPCS code(s) and specify the rental/certification period. Certification length cannot exceed 12 months; enter First Day and Last Day (MM-DD-YYYY).
- Requested HCPCS code(s) must be listed on the form (Item 11).
- Enter Rental Period / Certification Dates (First Day and Last Day).
- Certification length CANNOT exceed 12 months.
Prior Treatments for Oxygen Therapy
List prior treatments that were tried without success before initiating oxygen therapy. Include dates (begin and end) and specifics for bronchodilators, medications (name and dosage), physical therapy (percussors, breathing exercises), and any other treatments.
- Document bronchodilators tried (YES/NO) with start and end dates.
- Document medication name(s), dosage, and dates.
- Document physical therapy interventions (percussors, breathing exercises) with dates.
- Document any other prior treatments with dates.
Required Documentation on Form
Complete all required patient and clinical documentation on the form. Do not use 'INDEFINITE' for estimated duration—provide a specific number of months. Record patient ID, date last seen, diagnosis, prognosis, estimated months equipment needed, and mobility details (bed-, room-, wheelchair-confined; ambulatory status; disorientation). Include oxygen test results (PaO2 or oximetry), test date and setting, condition during test (rest, exercise, sleep), whether on room air or oxygen, prescribed unit type, hours per day, flow rate, and delivery method.
- Patient identification: name and subscriber number.
- Date patient last seen by doctor and diagnosis.
- Prognosis: Good/Fair/Poor.
- Estimated number of months equipment needed (do NOT put 'INDEFINITE').
- Mobility details: bed/room/wheelchair confined, ambulatory assistance, disorientation.
- Oxygen testing: report date, PaO2 or oximetry level, test location, condition during test, room air vs oxygen.
- Prescribed oxygen details: unit type (portable/stationary/concentrator/liquid/gaseous), hours per day (portable and non-portable), flow rate (L/min), delivery method (nasal cannula, mask), and exercise therapy specifics if applicable.
Physician Signature Requirement
The prescribing physician must complete, sign (handwritten signature required; stamped signature not acceptable), and date the form certifying active treatment and medical necessity. The physician's name, address, provider number, specialty, and office telephone must be included. Misrepresentation may constitute fraud.
- Attending physician's handwritten signature and date (stamped signature NOT acceptable).
- Physician's name, address, provider number, specialty, and phone number.
- Signed certification that the physician is actively treating the patient and the equipment is reasonable and necessary.
Background and Purpose
This certification/recertification form documents the prescribing physician's attestation of medical necessity for a range of durable medical equipment. The physician completes identifying information and provides an explicit certification that they are actively treating the patient and that the prescribed equipment is part of the present course of treatment and medically necessary. The signed certification is used to support coverage determinations for DME claims.
Definitions and Equipment Categories
Functional and Training Criteria for Medical Necessity
Functional/training criteria
Functional and training information must be provided as indicated on the form for the specific equipment selected.
See questions 13 and 14 in chunk 3
See mobility items in chunk 1
See question 16 in chunk 3
Rental and Purchase Rules
| Equipment | Rental rule / certification period |
|---|---|
| General DME rentals | Certification length cannot exceed 12 months; form requires entering first and last day of the certification period (rental period). |
| Required supplier information and HCPCS | Supplier name, provider number, and requested HCPCS code(s) must be recorded on the form for adjudication; rental period entered on form. |
| Equipment | Rental rule / certification period |
|---|---|
| Oxygen / IPPB | Certification length for oxygen/IPPB section cannot exceed 6 months. |
| IPPB-specific documentation | Provider must document current pulmonary function study results, IPPB frequency of use, and intended goals of IPPB use on the form. |
Documentation Retention and Required Details
Document PaO2/oximetry results and supplier/HCPCS details on form
Retain and place current PaO2 or oximetry blood gas study results on the certification form (report date, PaO2 level or oximetry level) and indicate where the test was performed; also list requested HCPCS codes, supplier name and provider number, and the rental/certification period on the form.
- Include PaO2 or oximetry results and report date; note condition during test (at rest, during activity, while sleeping) and whether on room air or oxygen.
- Document where test was done (home, doctor's office, nursing home, independent lab, hospital, ASC).
- List requested HCPCS code(s), supplier name/address/phone, and supplier provider number, plus certification First Day and Last Day.
Handwritten physician signature required (no stamps)
Attending physician's handwritten signature and date are mandatory on the certification form; stamped signatures are explicitly not acceptable.
- Handwritten signature required in the Attending Physician signature block.
- Stamped signature is not acceptable and will not meet the form requirement.
Exclusions and Not Covered Items
NOT COVERED: Equipment prescribed solely for convenience rather than because it is reasonable and necessary. The form requires the physician to attest that the item is not prescribed as convenience equipment; failure to meet this standard removes coverage eligibility.
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