Indiana Health Coverage Programs (IHCP) requires this certificate of medical necessity for home oxygen. It has four sections: supplier and patient details, clinical questions on blood gas or saturation tests and flow rate, the supplier's equipment description and charges, and the physician's attestation. The supplier keeps it and attaches it to the prior authorization request.
The supplier may complete Section A and must complete Section C. Section B may not be completed by the supplier; a non-physician clinician or physician employee may answer it, but the treating physician reviews it and signs Section D.
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Certificate of Medical Necessity for Oxygen
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Not the supplier. Section B may be completed by the physician, a non-physician clinician or a physician employee, who prints their name, title and employer if they are not the physician. The treating physician must still review it and sign the attestation in Section D.
That they are the treating physician named in Section A, that they received Sections A, B and C including the charges for the items ordered, and that the Section B medical necessity information is true, accurate and complete. The signature also certifies the items are medically necessary.