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Certificates of Medical Necessity (CMNs) and Other Forms Used by DME MAC Jurisdiction A

Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs)

On October 1, 2006 CMS released a new series of CMN and DIF forms for use by all DME Suppliers. The below table contains links to the new CMNs and DIFs which are also available on the CMS web site.

DME Form Number	CMS / DIF Form Number	Items Addressed
484.03	484	Home Oxygen Therapy
04.04B	846	Lymphedema Pumps (Pneumatic Compression Devices)
04.04C	847	Osteogenesis Stimulators
06.03B	848	Transcutaneous Electrical Nerve Stimulators (TENS)
07.03A	849	Seat Lift Mechanisms
11.02	854	Section C Continuation (Manual/Motorized Wheelchairs-ONLY)
09.03	10125	External Infusion Pumps
10.03	10126	Enteral and Parenteral Nutrition

For more information about CMNs and DIFs the following Web sites:

• DMEPOS Information Resource for Medicare - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Information Resource for Medicare, provided by CMS.

CMS Forms

The below links lead to the Centers for Medicare & Medicaid Services (CMS) web site. These forms along with other CMS forms can be found on the CMS web site at http://www.cms.gov/CMSForms/ .

• Advance Beneficiary Notice (ABN) (CMS-R-131)
  
  
• National Supplier Clearinghouse (NSC) Application for DMEPOS Suppliers (CMS 855S)
  
  
• Form CMS-1500 (08/05) - Blank CMS-1500 forms are not distributed by Medicare contractors. In order to purchase claim forms, contact the U.S. Government Printing Office at 202-512-1800, local printing companies in your area, and/or office supply stores. Each of these vendors sells the CMS-1500 form in its various configurations. The only acceptable claim forms are those printed in Flint Red, J6983, (or exact match) ink. Photocopied claims should not be submitted to Medicare contractors.
  
  
• Medicare Reconsideration Request Form (CMS 20033) - A written reconsideration request must be filed with a QIC within 180 days of receipt of the redetermination. To request a reconsideration, follow the instructions on your Medicare Redetermination Notice (MRN). A request for a reconsideration may be made on the standard form CMS-20033. To access the Reconsideration Request Form click the link above then scroll down to the “Downloads” section.
  
  

Suggested Forms

• Statement of Certifying Physician for Therapeutic Shoes
  
  
• Statement of Ordering Physician - Group 1 Support Surfaces
  
  
• Statement of Ordering Physician - Group 2 Support Surfaces
  
  
• Medicare Capped Rental and Inexpensive or Routinely Purchased Items Notification for Services on or after January 1, 2006
  
  

DME MAC Forms

The Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC) maintains the forms listed below as a convenience for our supplier community.

• ADMC Request Form (27KB) - Use this cover sheet when submitting requests for Advance Determination of Medicare Coverage (ADMC).
  
  
• Medicare Reopening Request Form (47KB) - The new Reopening Request Form is for all DMEPOS suppliers to use when submitting a Reopening request. The new form is designed so that users can easily include all of the basic information needed to submit a Reopening request and is valid in all four DME MAC Jurisdictions. A Checklist (39KB) and Interactive Form (484KB) are also available to assist in completing the new form.
  
  
• DME Immediate Offset Request Form (22KB) - Use this form when requesting an immediate offset.
  
  
• Overpayment Refund Form (51KB) - Use this cover sheet when submitting voluntary refunds for an overpayment situation. New Fax Number.
  
  
• Medicare Redetermination Request Form (49KB) - The Redetermination Request Form is for all DMEPOS suppliers to use when submitting a redetermination request. The form is designed so that users can easily include all of the basic information needed to submit a redetermination request and is valid in all four DME MAC Jurisdictions. A Checklist (85KB) and Interactive Form (500KB) are also available to assist in completing the form.
  
  
• In coordination with the New England Medical Equipment Dealers (NEMED) Association, NHIC, Corp. DME MAC A has developed the attached letter for use by our New England supplier community for submission to MassHealth Medicaid. MassHealth has agreed to the use of this generic letter rather than requiring each supplier to individually request this type of letter from DME MAC A. Note: This letter is to be used only for MassHealth. Any additional letters of this type would have to be coordinated through your state DMEPOS association or the office of your local Medicaid or private insurer. This letter is being provided in PDF format and can not be electronically altered. This form must first be printed in order to complete the required information for submission to MassHealth. If you have any questions relating to this specific letter, please contact either NEMED at 508-993-0700 or DME MAC A Customer Service at 866-419-9458.
  
  2008 MassHealth Medicaid Letter (30KB)


2009 MassHealth Medicaid Letter (30KB)

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12/22/2011