CM-893 Certification of Medical Necessity

Certification of Medical Necessity

U.S. Department of Labor Office of Workers’ Compensation Programs Division of Coal Mine Workers’ Compensation

Completion of this form and prior approval is required when making an initial request for the Department of Labor to authorize reimbursement charges for equipment and home nursing care (30 U.S.C. 901 et seq. and 20 CFR 725.705 and 725.706). If granted, the authorization covers a maximum period of one (1) year, subject to renewal. Fill in all applicable items. (See DOL Reimbursement Standards under Item eleven (11)). This form must be signed and dated by the treating physician. Collection of this information is required to obtain a benefit. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

OMB No.: 1240-0024 Expires: 05/31/2024

1. Patient’s Name and Mailing Address Name: ________________________________________________________

2. Telephone Number ( ) _________ - ___________

3. DOL’s Case ID Number:

Line 1: ___________________________ City: _______________________ Line 2: ___________________________ State: ______ Zip: ____________

4. Date of Birth

5. Patient’s Last Four Digits of Social Security Number

6a. Date(s) of last hospitalization From: _________________________ To: _________________________

6b. Condition(s) treated while in the hospital

7. Pulmonary Condition(s) for which this prescription is written:

8a. Type of Prescription Original (New) Recertification (Renewal)

8b. Requested Duration of Prescription for DME or Home Nursing (see 11c). Beginning Ending Date: ________________ Date: _______________

9. EQUIPMENT OR SERVICE PRESCRIBED (SEE Item 11 FOR CORRESPONDING DOL REIMBURSEMENT STANDARDS)

9a. Oxygen Delivery Equipment (11 a.) Prescription: Flow Rate (L/M) ________­­______________ Est. Hrs./Day ______________________  Tank O2 With Flowmeter and Humidifier  O2 Concentrator  O2 Liquid System  Portable Unit (Gaseous)  O2 Liquid System with Portable Liquid

9b. Other Durable Medical Equipment (DME): Manual Hospital Bed/Mattress (11 b.)  Wheelchair (11 d.) Semi-electric Hospital Bed (11 b.)  Other (Explain in Item no. 12.)

9c. Prescription for Medical Services  Home Nursing Care (See 11 c.)

Objective Test Results – All lab reports must be attached, including tracings for each PFT. The following data (10A through 10D for a PFT; 10E through 10I for an ABG) MUST BE reported below OR on the attached lab report. (Note: Patient’s condition is considered ACUTE if test was taken during a hospitalization for a covered pulmonary condition.)

A. Pulmonary Function Test (see 11e.) Date of test: |___|___|___| Pt.’s condition: MM DD YY  Acute Results:  Chronic (Best Effort)

B. Check as appropriate (if “poor”, explain in Item 12 “Comments”) Miner’s Cooperation:  Good  Fair  Poor Miner’s ability to understand instructions and follow directions:  Good  Fair  Poor

Predicted

Bronchodilation

C. Was equipment calibrated before the test?  Yes  No (Explain Under Item 12.)

Before

After

FEV1 L/BTPS

D. Testing Facility Name and Address: Name: Line 1: City: Line 2: State: Zip:

FVC L/BTPS

E. Arterial Blood Gas Test (see 11e.) Date of test: |___|___|___| Pt.’s condition: MM DD YY  Acute  Chronic

F. Air Intake:  On room air  On O2 @ __________LPM

G. Time Sample Drawn Iced Time Sample Analyzed ______________  Yes _____________________  No

Results:

PO2

PCO2

PH

H. Was equipment calibrated before the test?  Yes  No (Explain Under Item 12.)

I. Testing Facility Name and Address Name: line 1: City: line 2: State: Zip:

CM-893 (REV. 11-23)

11. DOL/DCMWC REIMBURSEMENT STANDARDS
11a.		For Home O2 Delivery equipment: requires a pO2 value of 60 mmHg or less on room air during a chronic state with corresponding pCO2 and pH values. If the ABG is done while the patient is on O2, the pO2 standard = 80 mmHg for all oxygen equipment (See 11e). All medical evidence to support your request will be considered. If the patient is homebound or non-ambulatory, or if other circumstances related to his/her condition prevent the sample from being analyzed within 30 minutes, the prescribing physician may submit a narrative rationale explaining the circumstances and substantiate the medical necessity for the item or service prescribed.
11b.		Hospital Bed/Mattress: must be justified by PFT results indicating an FEV1 equal to or less than 40% of predicted, or chronic hypoxia (pO2 of 55 mmHg or less). PFT – Test results with tracings and flow volume loop must be attached. ABG – Test strip must be attached.
11c.		Prescriptions for home care: must include objective test results or comparable clinical data, explanation why the patient is homebound, and a specific schedule of services to be rendered, including the total number and frequency of prescribed visits. Indicate the type of medical professional (PA, RN, LPN, RT) providing care. Use Item 12, below, and/or attach separate sheet.
11d.		Wheelchair is not a commonly covered item. Requests must include medical support data and will be evaluated individually. Data must support the wheelchair need because of a severe pulmonary impairment.
11e.		ALL CMN supportive test results: must be dated 2 months or less prior to prescription for services. Recertification services for home nursing care and equipment must be reviewed yearly or at the expiration date. PFT – Test results with tracings and flow volume loop must be attached. ABG – Test strip must be attached.
		NOTE:	Prescription for indefinite services or those without required objective test data will be returned for specific information. If your request is rejected because your patient’s medical condition does not meet DOL reimbursement requirement standards, you may submit other medical evidence to support your prescription request. All evidence will be considered.
12. If “OTHER” is checked in block 9b the DME narrative or CPT/HCPCS code is required, as well as Supporting Medical documentation justifying the medical need of the DME item is also required:
13. PHYSICIAN/PROVIDER INFORMATION
a. Prescribing Physician’s Name, Address and Phone Number (print or type) Name: _____________________________________________________ Line1: __________________________ City: ______________________ Line 2: __________________________ State: _____ Zip: ____________ Phone: __________________________					b. Are you the patient’s regular physician or are you actively treating this patient?  Yes  No If NO, explain why you are prescribing the equipment or services on this form.
c. Date of Visit (the date you examined the patient and made the decision. for this prescription):				|___|___|___| MM DD YY	d. Date that the prescribed treatment or service is authorized to begin: |___|___|___| MM DD YY
e. I certify that I am the current treating physician (or have provided an explanation in 13b. above) and that the prescribed equipment and/or services on this form are medically necessary for treating this patient’s covered pulmonary condition. I also certify that all data accompanying the submission is an accurate representation of the test results. Any statement on my letterhead attached hereto, has been reviewed and signed by me. I understand that any falsification, omission, or concealment of medical fact may subject me to civil or criminal liability.
Physician’s Signature						Date
TWO FILING OPTIONS: To file electronically, submit completed form and accompanying medical documentation to the COAL Mine Portal: https://coalmine.dol.gov To file by mail, submit completed form and accompanying medical documentation to: US Department of Labor OWCP/DCMWC/CMR Correspondence PO Box 8307 London, KY 40742-8307 For further information call TOLL FREE: 1-800-347-2502.					f. Name, Address, Phone No., and PROVIDER NO. of provider who is supplying the equipment or service: Name: _______________________________________________________________ Line1: _________________________________ City: __________________________ Line 2: _____________________________ State: ________ Zip: ________________ Phone: ____________________________ Provider No.: _______________________
	PRIVACY ACT In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) the Black Lung Benefits Act (BLBA) (30 U.S.C. 901 et seq.), as amended, is administered by the Office of Workers' Compensation Programs (OWCP) of the U.S. Department of Labor, which receives and maintains personal information, relative to this application, on claimants and their immediate families; (2) information obtained by OWCP will be used to determine eligibility for benefits payable under the BLBA; (3) information may be given to other government agencies, coal mine operators potentially liable for payment of the claim or to the insurance carrier or other entity which secured the operator's compensation liability, contractors providing automated data processing services to the Department of Labor; and representatives of the parties to the claim; (4) information may be given to physicians or other medical service providers for use in providing treatment, making evaluations and for other purposes relating to the medical management of the claim; (5) information may be given to the Department of Labor's Office of Administrative Law Judges, or other person, board or organization, which is authorized or required to render decisions with respect to the claim or other matters arising in connection with the claim; (6) information may be given to Federal, state or local agencies for law enforcement purposes, to obtain information relevant to a decision under the BLBA, to determine whether benefits are being or have been paid properly, and where appropriate, to pursue administrative offset and/or debt collection actions required or permitted by law; (7) disclosure of the claimant's or deceased miner's Social Security Number (SSN) or tax identifying number (TIN) on this form is voluntary, and the SSN and/or TIN and other information maintained by the OWCP may be used for identification and for other purposes authorized by law; (8) failure to disclose all requested information, may delay the processing of this claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits; and (9) this information is included in a System of Records, DOL/OWCP-2 published at 81 Federal Register 25765, 25858 (April 29, 2016) or as updated and republished.
	Public Burden Statement We estimate that it will take an average of 20-40 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the Division of Coal Mine Workers’ Compensation, U. S. Department of Labor, Room 200 Constitution Avenue, N.W., Suite C3520-DCMWC Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
	Notice If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from OWCP in the form of communication assistance, accommodation, and modification to aid you in the claims process. For example, we will provide you with copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact our office or the claims staff to ask for assistance.
CM-893 PAGE 2 (REV. 11-23)