Certificate of medical necessity attached to claims for items/services that require documentation of medical necessity.
- Completed by
- Prescribing provider
- Issued by
- Kansas Medical Assistance Program (KMAP)
- Format
- Fillable PDF
- Language
- English
MO HealthNet Certificate of Medical Necessity 2575-016
MO HealthNet requires form 2575-016 for each procedure that needs documentation of medical necessity, and it accompanies the claims for those procedures, services or circumstances. The form must state fully and clearly why the item, service or supply was needed for this particular participant and detail the risk to the participant if it had not been provided.
Who completes it
The attending or prescribing physician gives name and NPI, the date prescribed, diagnosis and prognosis, and signs. The billing provider lists up to six procedure codes with modifiers, describes each item or service and the reason for it, and signs the provider block.
Submitting and payment
- How to submit it
- Submit it with the claim through eMOMED. For durable medical equipment, do not attach it to the claim: send it separately through eMOMED or by mail to the claims address printed on the form.
- Who pays
- The certificate supports the billing provider's MO HealthNet claim for reimbursement of the procedure, service or item it documents.
Good to know
- One form holds up to six procedure codes, each with up to four modifiers, a description of the item or service and the reason it is needed.
- For DME, enter the number of months the item is needed; that field applies to durable medical equipment only.
- Write the reason for this specific participant: MHD requires the form to describe the risk to the participant if the service had not been provided.
- The current version is dated February 2023. Prior authorization requests for medical services and DME use a different form, 2575-034, Prior Authorization Request.
Get the official form
Download the current version from the source each time; forms change without notice.
Certificate of Medical Necessity
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Frequently asked questions
Who signs MO HealthNet form 2575-016?
Two people sign. The attending or prescribing physician signs and dates the physician block, which also carries their NPI, the date prescribed, diagnosis and prognosis. The provider submitting the claim signs the provider block with its name, NPI and address.
Does form 2575-016 go with the claim?
For most procedures, yes: it is submitted with the claim through eMOMED. DME is the exception. For durable medical equipment the certificate is not attached to the claim but sent separately, either through eMOMED or by mail to the address on the form.
What should the reason for the item or service say?
MO HealthNet asks for the medical reason the item, service or supply was needed, stated fully and clearly, related to the particular participant, and detailing the risk to the participant if it had not been provided. Each procedure code line has its own description and reason.