Certification of Medical Necessity for Abortion
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This document is a fillable certification form and instructions used to document that an abortion is medically necessary for TennCare beneficiaries in Tennessee, including required fields, reasons for abortion, and supporting documentation.
No material clinical or coverage changes in this revision.
Coverage Criteria
Permitted certification reasons
Covered when ONE of the following is certified by the physician:
Physician must check the applicable box on the certification form and sign the form after the procedure; attach supporting documentation as specified elsewhere on the form.
The form permits certification of medical necessity only for specific clinical reasons. A physician must check one of the provided options: either there is credible evidence the pregnancy resulted from rape or incest or the abortion is medically necessary because the woman has a physical disorder, injury, or illness — including a life‑endangering condition caused by or arising from the pregnancy that would place her in danger of death unless an abortion is performed. The form does not include elective or non‑medical reasons as allowable bases for certification.
If neither of the two listed reasons applies, or if the required supporting documentation is not provided, the procedure cannot be certified as medically necessary on this form. The form requires the physician to indicate which permitted reason applies and to attach appropriate documentation (for example, law enforcement or public health/DHS/counseling agency reports for rape/incest, or medical records documenting the lifesaving nature of the abortion); absence of these materials prevents certification.
Provider Actions & Documentation
Certification form must be completed and signed
Complete and retain the Certification of Medical Necessity for Abortion form as part of the clinical record; the physician must sign and date the form in their own handwriting after the procedure.
- Physician must sign and date the form after the procedure (handwritten).
- Form is used to document clinical certification that an abortion is medically necessary.
Complete required fields and select the applicable reason
Ensure the required form fields are completed accurately and the physician attests based on professional judgment to one permitted reason for the abortion.
- Check one applicable reason box on the form (rape/incest OR life‑endangering physical condition).
- Complete patient identifying fields: date of service, full name, date of birth, and address.
Complete form fields and attach required documentation
Attach the specified supporting documentation and complete provider identification and signature fields as instructed.
- Mark the Supporting Documentation block and attach one of the listed documents (law enforcement report; public health/DHS/counseling agency report; or medical records).
- Provide physician NPI and complete physician address on the form.
- Physician signature and date must be handwritten and provided after the procedure.
Insufficient supporting documentation may render certification invalid
Failure to attach the specified supporting documentation may prevent certification of medical necessity on this form.
- Acceptable attachments include: documentation from law enforcement; documentation from a public health agency, Department of Human Services, or counseling agency; or medical records documenting the lifesaving nature of the abortion.
- If neither permitted reason applies or required documentation is not attached, the abortion cannot be certified as medically necessary on this form.
Background
This certification form is used to document that an abortion is medically necessary for TennCare enrollees when either the pregnancy results from rape or incest or when the woman’s physical disorder, injury, or illness — including a life‑threatening physical condition caused by or arising from the pregnancy — places her in danger of death unless an abortion is performed. The physician completes and signs the form based on professional judgment to certify medical necessity for the specified reason.
Definitions
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