Georgia Medicaid requires this one-page certificate before it authorizes home oxygen equipment. The physician records a respiratory or cardiac primary diagnosis, the stationary and portable systems ordered, liters per minute, hours per day and qualifying blood gas or saturation results. The oxygen supplier submits it, with the lab report attached, as part of its prior authorization request.
The physician completes the clinical sections and signs the certification of medical necessity, including the date of the face-to-face evaluation. The supplier's name, address and NPI also appear on the form.
Download the current version from the source each time; forms change without notice.
Certification of Medical Necessity for Oxygen Equipment
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An arterial blood gas PO2 and/or oxygen saturation, marked as on room air or on a stated oxygen percentage, with the test date. A copy of the laboratory report must be attached to the prior authorization request. If the test was not on room air, the physician explains why on the form.
The ordering physician signs, certifying that the oxygen equipment is medically necessary, that they had a face-to-face evaluation with the member within the ten months before the order, and that they are enrolled with Georgia Medicaid to order, refer or prescribe. Signature and date stamps are not acceptable.