Medicaid Certificiate of Medical Need

The Ohio Department of Job and Family Services requires a Ambulette Certification of Medical Necessity or an Ambulance Certification of Medical Necessity for certain situations. These forms are required for practitioner certification of medical necessity for ambulette and ambulance transport. The forms have been created to ensure consistency with revisions to documentation requirements in transportation rule 5101:3-15-02.

The attending practitioner, or with an order from the attending practitioner a registered nurse signing for the attending practitioner, must complete an ODJFS 03452 or ODJFS 01960 for all the following medical transportation services.
  • Nonemergency ambulance or ambulette transportation
  • Transports to a physician's office.
  • Outpatient treatment center.
  • Outpatient testing.
  • Dialysis Treatment.
Download Forms Here:
Basically, any basic life support, non-emergency or ambulette transports except for trips to a emergency room or transports from hospital to hospital require these forms.  Even with a signed CMN, the patient must meet medical necessity for all transports.
A CMN is not required for the following types of transports.
  • ALS and/or BLS ambulance transportation to a hospital emergency room in an emergency situation; or
  • Ambulance or ambulette transfer of a non-ambulatory patient from one hospital to another hospital if the services provided at the second hospital are covered by Medicaid
If you have questions, please call our billing specialists at (937) 325-4651, option (1)