Ohio Medicaid uses this one-page certificate when medical supplies or equipment need a certificate of medical necessity or a need verification under its DMEPOS rules. The supplier can fill in identifying details, the medical section lists diagnosis codes, HCPCS codes, quantities and why each item should be authorized, and the prescriber signs the attestation. The supplier keeps it or sends it with a prior authorization request.
The supplier may complete the Identifying Information section and may transcribe the Medical Information section. The prescriber must complete and sign the Attestation.
Three columns identify the people involved. For the individual: name, Medicaid ID number, date of birth, height in inches, weight in pounds, sex, phone and street address. For the prescriber and for the provider (the supplier): name, Medicaid provider number and NPI. A note on the address field flags that certain equipment and supplies for long-term care facility residents are the facility's responsibility.
Check initial certification, change (optional) or renewal/continuation, and enter the previous prior authorization number when there is one. Then mark any attachments: a price list, an invoice or other documents, with a line to describe them. This tells Ohio Medicaid whether it is reviewing a new need or extending an existing authorization.
Enter the diagnosis codes that support the request, then up to 20 lines, each with a HCPCS code, a description of the item and the quantity requested. The supplier may transcribe this section, but the prescriber's attestation later covers everything on the form, so review the codes and quantities before signing.
Within the Medical Information section, explain why the listed items are medically necessary for this individual, then give the starting date for dispensing and the ending date. The explanation and dates are what the prescriber attests to, and they define the period the supplier dispenses under.
The prescriber signs and dates the statement attesting that the certification information above is true, correct and complete. Beneath it the form states in capitals that false certification constitutes Medicaid fraud. No one else may complete this section, so a supplier-prepared form must go back to the prescriber for signature.
Download the current version from the source each time; forms change without notice.
Certificate of Medical Necessity / Request for Need Verification: General Medical Supplies and Equipment
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Sources for this guide
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The prescriber. The Attestation section must be completed by the prescriber, who signs and dates it to attest that the certification information is true, correct and complete. The supplier may fill in identifying information and transcribe the medical information, but the attestation belongs to the prescriber alone.
Yes. The Purpose section lets the certificate be marked as an initial certification, a change, or a renewal/continuation, and asks for the previous prior authorization number. Each certificate carries its own starting and ending dates for dispensing and its own prescriber signature and date.
Not always. A note beside the street address field says that providing or paying for certain equipment and supplies used by a resident of a long-term care facility is the facility's responsibility. Check where the patient lives before the supplier submits the request.