Humana Military uses this one-page Certificate of Medical Necessity to support TRICARE East claims for durable medical equipment, including CPAP devices, breast pumps and capped rental items. The ordering provider certifies the diagnosis codes, HCPCS or CPT codes, quantity and length of need, and the DME supplier sends it with the claim so Humana Military can process it.
The ordering provider completes and signs it with the sponsor ID, beneficiary details, provider name and TIN, diagnosis codes, item lines and start and end dates of need; the DME supplier attaches it to the claim.
Download the current version from the source each time; forms change without notice.
Certificate of Medical Necessity (CMN)
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Capped rental items are covered for a 15-month period. If the CMN's start and end dates do not cover the entire rental period, another CMN will be required to process claims after the end date, so the length of need should reflect the full rental.
If the DME item is a CPAP device, the form asks for the beneficiary's oxygen levels so the device can be properly set. If it is a breast pump or breastfeeding supplies, it asks for the gestational age in weeks and the corresponding diagnosis code.
The ordering provider signs and dates it after entering the diagnosis codes, item codes, quantity, length of need and start and end dates. The DME supplier then sends it with the claim, including the claim's internal control number when one is available.