DI 11052.045:
Post-entitlement Issues and Processing End-Stage Renal Disease Medicare Appeals
Effective Dates: 05/15/2015 - Present- Effective Dates: 02/26/2018 - Present
- BASIC (05-11)
- DI 11052.045 Post-entitlement Issues and Processing End-Stage Renal Disease Medicare Appeals
- A. Documentation received in the field office (FO) reporting a change in treatment
- If the FO receives a CMS-2728 (End-Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration) or other documentation reporting a change in treatment such as dialysis stops or to report a transplant:
- * Fax the documentation to the Paper Processing Center (PPC) system using fax number (877) 385-0643.
- * Prepare an ESRD fax coversheet under Type-Of-Event-Level (TOEL) (ESRD Post-entitlement actions)
- * Fax all documentation into the Non Disability Repository for Evidentiary Documents (NDRed) under TOEL. (HISMI RENAL).
- If a person contacts the FO to report a change in treatment such as dialysis stops or to report a transplant, advise the caller that the ESRD beneficiary will be contacted if documentation is needed. The FO will develop for all necessary documentation before sending a Modernize Development Worksheet (MDW) to PC7.
- B. Termination of supplementary medical insurance (SMI) for non-payment of premiums
- If the beneficiary is requesting reinstatement and has “good cause” for reinstatement as explained in HI 01001.360, obtain an SSA-795 (Statement of Claimant or Other Person) or any signed statement from the claimant requesting “reinstatement” and an explanation of why the premiums were not paid. The claimant must be able to repay all past-due premiums, plan to repay them by installment, or have a third party who is willing to pay.
- Document the “good cause” determination on an SSA-5002 (Report of Contact) and send to PC7 via fax to the paperless server. Send a copy of the receipt you issued for payment received.
- If the beneficiary cannot pay the retroactive premiums or cannot establish good cause, he or she can re-file in the general enrollment period (GEP).
- Do not develop a new ESRD application if the beneficiary has hospital insurance based on ESRD (R-HI). The CMS-40B (Application for Enrollment in Medicare) is the appropriate form to request Supplementary Medical Insurance based on ESRD (R-SMI) enrollment.
- If the beneficiary has been covered by a Group Health plan, see DI 11052.001G and consider withdrawal of the ESRD application.
- NOTE: Special enrollment period (SEP) provisions do not apply to ESRD beneficiaries, including those dually entitled to Medicare based on ESRD and disability or age (ESRD/DIB, ESRD/RIB, ESRD/WIB).
- References:
- * HI 00801.197, Withdrawal of Application
- * HI 00801.247, Medicare as Secondary Payer of ESRD Benefits
- * HI 00805.265, The Special Enrollment Period–Definition
- * HI 01001.360, “Good Cause” Defined
- * HI 01001.355, Extension of Grace Period for Good Cause
- C. ESRD appeals
- * Route Reconsideration requests to PC7. PC7 completes another SSA-892 (End-Stage Renal Disease (ESRD) Medicare Determination) with their determination of award or denial. Item 19 of the SSA-892 indicates the level of RECON.
* Route all non-medical Medicare hearing requests to the Department of Health and Human Services’ Office of Medicare Hearings and Appeals (OMHA). For Medicare Qualified Government Employee (MQGE) and medical ESRD appeals cases, route the hearing requests to the Office of Disability Adjudication and Review (ODAR) for an ALJ decision. Associate the folder with the request and forward all pertinent material to the appropriate OMHA or ODAR hearing office.- * Route all non-medical Medicare hearing requests to the Department of Health and Human Services’ Office of Medicare Hearings and Appeals (OMHA). For Medicare Qualified Government Employee (MQGE) and medical ESRD appeals cases, route the hearing requests to the Office of Hearings Operation (OHO) for an ALJ decision. Associate the folder with the request and forward all pertinent material to the appropriate OMHA or OHO hearing office.
- * For MQGE cases for which SSA retains jurisdiction, route requests for review of a hearing decision to the Appeals Council.
- * For all cases forwarded to OMHA, see GN 03108.210 for routing instructions.
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