L_CC270 Certificate of Medical Necessity ModivCare_06-01-2022
ModivCare is an independent company providing transportation services to Blue Cross and Blue Shield of New Mexico (BCBSNM) through a
contractual arrangement between BCBSNM and ModivCare. The relationship between BCBSNM and ModivCare is that of independent contractors.
Such services are funded in part with the State of New Mexico.
Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
PROVIDER CERTIFICATION OF MEDICAL NECESSITY (CMN) FORM
FOR TRANSPORTATION ATTENDANTS
(Providers are required to complete this form for members 18 and older
requesting an attendant that is 18 and older.)
FAX to ModivCare: (866) 402-0522
PHONE: (866) 400-8233
TTY: (866) 288-3133
MEMBER INFORMATION MEDICAL PROVIDER INFORMATION
Date of Birth:
/ /
Sex:
M
F
Age:
BCBSNM Centennial ID#:
Medicaid #:
Phone #:
Patient/Member Name (Last, First, MI):
If attendant is medically necessary, please
continue filling out form below.
this box and return the form by fax to (866) 402-0522.
_____ Attendant is not medically necessary.*
Date: ___________________
Signature: ____________________________________
* Pursuant to NMAC Regulation 8.324.7 I., if the attendant is not medically
necessary, the member will not be able to take an escort on the trip.
LEVEL OF SERVICE REQUIRED BY MEMBER AND PRESCRIBED BY MEDICAL PROVIDER
Medically Necessary Attendant
Ambulatory + Personal Care Attendant
Wheelchair + Personal Care Attendant
Wheelchair Transport
Width of Chair:
Medical Equipment Needed Medical Necessity Criteria
Airway monitoring and/or suctioning
Oxygen
Ventilator-dependent
Other
Bed-Confined __ Hip/Leg//Back precautions
History of existing paralysis/CA
__ Cannot support self while seated in a wheelchair for transport distance
Confused/lethargic/comatose
__ Contractures
__ Decubitus ulcers/cannot sit safely
Other _____________________________________________________
L_CC270 Certificate of Medical Necessity ModivCare_06-01-2022
ModivCare is an independent company providing transportation services to Blue Cross and Blue Shield of New Mexico (BCBSNM) through a
contractual arrangement between BCBSNM and ModivCare. The relationship between BCBSNM and ModivCare is that of independent contractors.
Such services are funded in part with the State of New Mexico.
Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
Summarize member’s medical history, including physical exams, laboratory results, and prescriptions, establishing
the medical necessity for the prescribed level of service. (Additional documentation may be attached if necessary.)
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Estimated duration of level of service (check one): 90 Days 180 Days Other:
Fax completed form to: (866) 402-0522
Mail completed form to: Facility Department
(If mailing, please allow 2602 S. 47
th
Street, Suite 100
7-10 days for processing.) Phoenix, AZ 85034
This certification may be completed and signed only by the member’s attending physician, physician assistant, or
certified nurse practitioner to confirm a medically necessary level of service.
Knowingly providing false information on this certification may constitute fraud and may prevent the patient/member
from receiving further transportation services. If you have any questions, please contact ModivCare’s Facility
Assistance Department at (866) 400-8233.
I certify that to the best of my knowledge, the above information is true, accurate, and complete and the level of
service required for the patient’s/member’s transport is medically necessary for the patient’s/member’s health.
NAME: SIGNATURE: DATE:
L_CC270 Certificate of Medical Necessity ModivCare_06-01-2022
ModivCare is an independent company providing transportation services to Blue Cross and Blue Shield of New Mexico (BCBSNM) through a
contractual arrangement between BCBSNM and ModivCare. The relationship between BCBSNM and ModivCare is that of independent contractors.
Such services are funded in part with the State of New Mexico.
Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
To ask for auxiliary aids and services or materials in other
formats and languages at no cost,
please call 1-866-689-1523 (TTY/TDD: 711).
Blue Cross and Blue Shield of New Mexico complies with applicable Federal civil rights laws and does
not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue
Shield of New Mexico does not exclude people or treat them differently because of race, color, national
origin, age, disability, or sex.
Blue Cross and Blue Shield of New Mexico:
• Provides free aids and services to people with disabilities to communicate effectively with us,
such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats, other
formats)
• Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact Civil Rights Coordinator.
If you believe that Blue Cross and Blue Shield of New Mexico has failed to provide these services or
discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can
file a grievance with: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St.,
35
th
floor, Chicago, Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960,
[email protected]. You can file a grievance in person or by mail, fax, or email. If you
need help filing a grievance, Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
L_CC270 Certificate of Medical Necessity ModivCare_06-01-2022
ModivCare is an independent company providing transportation services to Blue Cross and Blue Shield of New Mexico (BCBSNM) through a
contractual arrangement between BCBSNM and ModivCare. The relationship between BCBSNM and ModivCare is that of independent contractors.
Such services are funded in part with the State of New Mexico.
Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
Para obtener asistencia y servicios auxiliares, o materiales en
formatos alternativos u otros idiomas sin costo,
llame al 1-866-689-1523 (TTY/TDD: 7-1-1).
Blue Cross and Blue Shield of New Mexico cumple con las leyes federales de derechos civiles
aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Blue
Cross and Blue Shield of New Mexico no excluye a las personas ni las trata de forma diferente debido a
su origen étnico, color, nacionalidad, edad, discapacidad o sexo.
Blue Cross and Blue Shield of New Mexico:
• Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se
comuniquen de manera eficaz con nosotros, como los siguientes:
o Intérpretes de lenguaje de señas capacitados.
o Información escrita en otros formatos (letra grande, audio, formatos electrónicos
accesibles, otros formatos).
• Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como
los siguientes:
o Intérpretes capacitados.
o Información escrita en otros idiomas.
Si necesita recibir estos servicios, comuníquese con Civil Rights Coordinator.
Si considera que Blue Cross and Blue Shield of New Mexico no le proporcionó estos servicios o lo
discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo,
puede presentar un reclamo a la siguiente persona: Civil Rights Coordinator, Office of Civil Rights
Coordinator, 300 E. Randolph St., 35
th
floor, Chicago, Illinois 60601, 1-855-664-7270, TTY/TDD: 1-
855-661-6965, Fax: 1-855-661-6960, [email protected]. Puede presentar el reclamo en
persona o por correo postal, fax o correo electrónico. Si necesita ayuda para hacerlo, Civil Rights
Coordinator está a su disposición para brindársela.
También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de
Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios
Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal,
disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente
dirección o por teléfono a los números que figuran a continuación:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.
L_CC270 Certificate of Medical Necessity ModivCare_06-01-2022
ModivCare is an independent company providing transportation services to Blue Cross and Blue Shield of New Mexico (BCBSNM) through a
contractual arrangement between BCBSNM and ModivCare. The relationship between BCBSNM and ModivCare is that of independent contractors.
Such services are funded in part with the State of New Mexico.
Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
ATTENTION: If you speak English, language assistance services, free of charge, are available to you.
Call 1-855-710-6984 (TTY: 711).
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-855-710-6984 (TTY: 711).
Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dę
́
ę
́
’, t’áá jiik’eh, éí ná
hólǫ
́
, kojį’ hódíílnih 1-855-710-6984 (TTY: 711).
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.
Gọi số 1-855-710-6984 (TTY: 711).
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung. Rufnummer: 1-855-710-6984 (TTY: 711).
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-710-6984
(TTY: 711)。
ﻤﻟﺎﺑ ﻚﻟ ﺮﻓاﻮﺘﺗ ﺔﯾﻮﻐﻠﻟا ةﺪﻋﺎﺴﻤﻟا تﺎﻣﺪﺧ نﺈﻓ ،ﺔﻐﻠﻟا ﺮﻛذا ثﺪﺤﺘﺗ ﺖﻨﻛ اذإ :ﺔظﻮﺤﻠﻣﻢﻗﺮﺑ ﻞﺼﺗا .نﺎﺠ1-855-710-6984
:ﻢﻜﺒﻟاو ﻢﺼﻟا ﻒﺗﺎھ ﻢﻗر)711.(
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-855-710-6984 (TTY: 711) 번으로 전화해 주십시오.
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika
nang walang bayad. Tumawag sa 1-855-710-6984 (TTY: 711).
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855-710-6984
（TTY: 711）まで、お電話にてご連絡ください。
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.
Appelez le 1-855-710-6984 (ATS: 711).
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica
gratuiti. Chiamare il numero 1-855-710-6984 (TTY: 711).
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.
Звоните 1-855-710-6984 (телетайп: 711).
  :               
1-855-710-6984 (TTY: 711)   
ب ا . ب ﺎ ﺷ د ﻢ ﯾ ف ر ﺎ ﮭ ﻣ ﺶ ﻣ ا ب ر ﺎ ﯾ رﺎﯿﮔﺎﻧ ص و ﺮ ﺗ ﺐ ھ ﺰ ﺑ ﺎ ﻨ ﯾ ﺖ ﺴ ﮭ ﯾ ﻼ ﺗ ، ﮏﻨﯾد ﻢ ﯾ ﮓ ﻔ ﺘ ﮔ و ف ا ﺮ ﺴ ﯾ ﺰﺑﺎﻧ ﺐ ھ ﺎ ﮔ ر : تﻮﺠھ
. ﺐﮕﯾﺮﯾد ﺖ ﻣ ﺎ ﺳ (TTY: 711) 1-855-710-6984
เรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 1-855-710-6984
(TTY: 711).