Try for free

Health First Colorado Oxygen CMN

Health First Colorado, the state's Medicaid program, uses this certificate to document medical necessity for home oxygen at initial certification, revision or recertification. It records the most recent arterial blood gas or oxygen saturation result and the test conditions, the highest flow rate ordered, portable oxygen needs and the estimated length of need. The supplier retains it in the member's file.

Who completes it

The supplier completes Section A (certification type, member, supplier, HCPCS code, practitioner) and Section C, a narrative of items ordered and their cost. Section B's medical answers need not be written by the practitioner, but the qualified licensed practitioner reviews Sections A to C and signs the Section D attestation.

Submitting and payment

How to submit it
Return the signed certificate to the oxygen supplier, which keeps it in the member's file and uses it to support its prior authorization request and claims.
Who pays
The certificate supports the oxygen supplier's Health First Colorado request and claims; Section C lists the charges for the items ordered.

Good to know

  • Enter the most recent PO2 or oxygen saturation taken on or before the certification date, and mark whether it was at rest, during exercise or during sleep.
  • If more than 4 LPM is prescribed, question 6 asks for a test taken on 4 LPM with the member in a chronic stable state.
  • Questions 7 to 9, on edema from heart failure, cor pulmonale or pulmonary hypertension, and hematocrit above 56%, apply only when PO2 is 56 to 59 mm Hg or saturation is 89%.
  • Signature and date stamps are not accepted. Length of need is entered in months from 1 to 99, where 99 means lifetime. The form is revised September 2021.

Get the official form

Download the current version from the source each time; forms change without notice.

Health First Colorado Certificate of Medical Necessity for Oxygen Benefits

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

See how Vero Documents works

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who completes the Health First Colorado oxygen CMN?

The supplier fills in Section A and the equipment and cost narrative in Section C. The medical answers in Section B do not have to be written by the practitioner, but the qualified licensed practitioner responsible for the member's care must review the form and sign Section D, certifying that Section B is true, accurate and complete.

What test results go on the Colorado oxygen certificate?

The most recent arterial blood gas PO2 and/or oxygen saturation taken on or before the certification date, the test date and whether it was at rest, during exercise or during sleep. If more than 4 LPM is ordered, a second result taken on 4 LPM in a chronic stable state is also required.

What else does Colorado require for high-flow oxygen?

For oxygen over 6 liters per minute, Health First Colorado also uses DMEPOS Questionnaire #16, attached to the prior authorization request along with the certificate. It is one of about 20 item-specific questionnaires the state uses for durable medical equipment.