Home Care Medical

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Insurance Guidelines + Updates

CMN’s

Certificates of Medical Necessity (CMN)/Durable Medical Equipment Information Forms

Overview
A Certificate of Medical Necessity (CMN) or DME Information Form (DIF) are forms that help document the medical necessity and other coverage criteria for selected durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items. The Documentation section of each individual medical policy shows which items require one of these forms.

Certificates of Medical Necessity contain Sections A through D; Sections A and C are completed by the supplier and Sections B and D are completed by the physician. A DIF is completed and signed by the supplier. Unlike, the CMN, the DIF does not require a narrative description of the equipment and cost or a physician signature.

For certain items or services billed to the durable medical equipment Medicare administrative contractor (DME MAC), the supplier must receive a signed CMN from the treating physician or the supplier must complete and sign a DIF. A supplier must have a faxed, photocopied, an original signed order, or an electronically signed version of a CMN or a completed DIF in their records before they can submit a claim for payment to Medicare. The Centers for Medicare & Medicaid Services (CMS) form number is located in the bottom-left corner of the form. CMNs and DIFs are referred to by their CMS form numbers. DME form numbers identify the CMN on electronic claims submitted to the DME MAC. For example, CMS Form 484 serves as the CMN for oxygen. CMS Form 10125 serves as the DIF for External Infusion Pump.

For more information, download: CMN Instructions