DI 45001.005: Processing ESRD Claims

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~~Effective Dates: 01/07/2016 - Present~~
Effective Dates: 01/10/2018 - Present
TN 2 (07-04)
DI 45001.005 Processing ESRD Claims
A. Background
We have received reports of FOs misrouting the CMS-2728-U3 and ESRD claims to various PSCs. Since these cases are processed only by Office of Disability Operations (ODO), the misrouting and improper screening of the CMS-2728-U3 causes unnecessary delays in establishing Medicare coverage. This section provides clear and concise instructions for the screening and routing of the CMS-2728-U3 and should improve the processing of this high priority workload.
B. Procedure
1. CMS-2728-U3
The form CMS-2728-U3 is a medical form for ESRD entitlement, not an application for ESRD. When a CMS-2728-U3 (formerly known as the HCFA-2728) is received in the FO, the beneficiary's current Medicare status must be determined before a claim is taken and before the CMS-2728-U3 is forwarded to ODO. An ESRD application must be filed (e.g., a paper CMS-43 or an electronic ESRD application via MCS, which is the preferred method of filing) before ODO can establish R-HI/R-SMI entitlement on the MBR.
2. Insured status
The beneficiary must be fully or currently insured (see RS 00301.110), or be the spouse or dependent child of a person who is a monthly beneficiary or fully or currently insured, in order for an ESRD claim to be approved. A beneficiary who is currently an M (or a totalized beneficiary) on the MBR is not fully insured, but may be currently insured for ESRD (HI 00801.201). A M (or a totalized beneficiary) either with no HI coverage or with premium HI coverage would thus be advised to file for ESRD if current insured status is met.
3. Beneficiary has Medicare based on disability
If the MBR shows that the claimant has Medicare based on disability, the FO should always develop an application for ESRD when the CMS-2728-U3 is received. This is required to protect the beneficiary since R-HI may continue after D-HI terminates.
4. The individual with ESRD is filing for or already entitled to HI on the basis of attainment of age 65
It is not necessary to obtain an application unless there would be an advantage to the beneficiary. There would be an advantage if the beneficiary:
* is not currently enrolled in SMI;
* dies after signing the CMS-2728-U3 but before a Medicare application is filed (HI 00801.196.);
* is paying an increased premium because of late enrollment in SMI;
* has recently become entitled to HI and SMI for the aged and entitlement to R-HI and R-SMI would result in an earlier entitlement date; or
* is enrolled for Premium-HI.
5. When a CMS-2728-U3 is received for a beneficiary who is currently entitled to premium HI
The FO should query the earnings record(s) to see if there is a possibility for current insured status. The claimant would be eligible for free Part A effective with the first month of the quarter that insured status is acquired. The claimant's Premium Part A coverage, if any, would be terminated the same month and converted to free Part A. (If the beneficiary is a M, he/she would be converted to a T.)
Also, in the instance that the claimant subsequently marries a currently or fully insured NH, the claimant is considered a spouse effective the month of marriage for ESRD Medicare purposes. The NH does not have to be age 62. The FO should contact the claimant via telephone to screen for marital status.
6. ESRD entitlement already established based on dialysis (3-month qualifying period)
If the CMS-2728-U3 received in the FO shows that the claimant completed the self-dialysis training at an approved renal facility, the qualifying period can be waived. FOs must forward the CMS-2728 to ODO (under a routing flag) for manual action to establish the earlier ESRD start date (MACADE action required).
7. Disposition of the CMS-2728-U3
If the individual does not wish to file for R-HI because of an Employer Group Health Plan, return the CMS-2728-U3 to the renal facility (HI 00801.258E).
If the individual is 65 or over and there is no advantage as stated in the above scenarios, destroy the CMS-2728-U3.
If the requirements for entitlement are met, process and forward the case to ODO. The CMS-2728-U3, regardless of the MBR jurisdiction, is not to be sent to PSCs 1 through 6 for filing purposes or to document changes in dialysis or transplant information. All ESRD claims are processed and maintained by ODO.
8. Preparation of folder for transmittal of end stage renal disease claim (ESRD)
Prepare the folder in accordance with GN 01050.165 except that it will not be necessary to enter the claimant's name on the reverse of the folder tab. Scan the ESRD documentation to CFRMS or eView and assemble the material in the folder following the guidelines in GN 01050.190. Enter "ESRD" below the upper right edge of the front face of the folder of identification purposes. Send all ESRD claims to: SSA OCO/ODO 1500 Woodlawn Drive Baltimore, MD 21241-1500
Prepare the folder in accordance with GN 01050.165 except that it will not be necessary to enter the claimant's name on the reverse of the folder tab. Scan the ESRD documentation to Claims File User Interface (CFUI) or eView and assemble the material in the folder following the guidelines in GN 01050.190. Enter "ESRD" below the upper right edge of the front face of the folder of identification purposes. Send all ESRD claims to: SSA OCO/ODO 1500 Woodlawn Drive Baltimore, MD 21241-1500
A general reminder for FOs: Any situation that requires a manual action should be sent to ODO with BOLD INSTRUCTIONS THAT A MANUAL ACTION IS REQUIRED.
C. Claims received from field office (FO)
The FOs have the authority to finally authorize (i.e., DOFA) all initial ESRD Medicare awards and disallowances except when:
* a disability determination prior to age 22 for a dependent child is needed,
* a closed period of R-HI is being award, or
* it is prepared in accordance with a reconsideration, ALJ, AC, or court decision.
The primary FO procedures for processing ESRD Medicare claims are contained in HI 00801.300.
D. ODO incoming mail responsibilities
* All OCO/ODO mail will be referred, immediately upon receipt, as indicated by the SSN.
* Label the folders using the 70151 code. Loose material will be handled on a priority basis for folder association and referral to a Benefit Earnings Technician (BET) or Benefit Authorizer (BA).
* A readout should be quickly obtained and then (if necessary) the case control system should be immediately updated to permit the most accurate response in the events of field query and to determine related folder locations and accessibility. Only the association of prior related folders which are immediately available from MOD files can be a basis for delaying the referral of the ESRD claim for processing. ESRD claims folders (with or without the prior folders if one exists) must be expeditiously referred for adjudication and notification of the claimant, after which any unassociated folders may be obtained, if required for consideration prior to systems input. If the readout shows a related claim in files, but it cannot be located show “UTL” on the printout.
* Examine the ESRD folder to determine proper routing of the claim for adjudication. All ESRD Medicare folders will be dispatched to the addressee shown on the transmittal sheet (i.e., Disability Examiner (DE) or BA), otherwise all others will be dispatched to the BET.
E. ODO benefit earnings technician (BET) and benefit authorizer (BA) responsibilities in non-DOFA cases
* Verify that the claim has been properly referred. If the claim should have been dispatched directly to a BA (DI 45001.313, DI 45001.326, DI 45001.313, and HI 00801.302) or to any other addressee in accordance with POMS procedures, the BET will redirect the claim immediately without review.
* Verify the correctness of the claimant's SSN(s) and any other SSN used to establish insured status for the claimant, and all the other items (in DI 45001.005) for which the FO is responsible.
* Verify from the case control readout whether a related folder exists which is not attached. If a related folder does exist in any other locations, do not delay the adjudication of the ESRD claim. Instead, obtain an MBR (if not already attached when the ESRD claim was received) for use in place of the related folder.
* Correct any improper FO processing (see HI 00801.300). If necessary to develop, when possible, telephone the FO to avoid undue delay considering the priority nature of non-adjudicated ESRD claims.
* Determine whether all the nonmedical requirements for entitlement are met. Develop by telephone to the FO those nonmedical factors which are not resolved. Refer to OD, DVRSP, SPB, 3-M-25 Operations Building, those cases in which questionable factors cannot be developed. When it is clear that any nonmedical factor is not met and that factor is essential to allowance of the claim, prepare a technical denial on SSA-892-U3 per DI 45001.025. Notify the claimant using DI 45001.076 and its appropriate fill-in as a guide-letter. Specific details of nonmedical review are contained in DI 45001.010.
* If all nonmedical factors of entitlement are met, review the medical evidence (generally Form CMS-2728-U3, but occasionally, narrative medical reports). Be guided by DI 45001.015. If all copies of the CMS-2728-U3 are in the folder, retain the original in the folder and forward the copies to CMS. ESRD System Branch, 1-C-15 Oak Meadows Building via OMR mailroom. Prepare Form SSA-892-U3 as appropriate from DI 45001.015, DI 45001.020, and DI 45001.025. Complete the necessary CAPS orbit or award forms, forms to establish a temporary HI record, Form SSA-1598 (per DI 45005.001) if case requires a future termination date to be manually established or corrected in the “prior coverage” field of the MBR, and diary forms. (Be alert to the existence of HI and/or SMI entitlement based on age 65 or disability. If HI and/or SMI entitlement already exists do not prepare an award form. However the SSA-892-U3, HCFA-8003, and needed diary form, and notice per DI 45001.081 through DI 45001.086 must be prepared. The case should then be referred to the benefit authorizer via SSA-559 per DI 45001.030. The difference in premium consideration and the change in MBR indicators will be accomplished by the benefit authorizer.) In all cases with applications for ESRD Medicare, the BET/BA must provide for the appropriate notification letter, selecting guides from DI 45001.076 through DI 45001.091.
* An award granting earlier entitlement may not be made until there is evidence of actual transplant surgery unless the person dies during transplant surgery.
In order to establish entitlement based on hospitalization for transplant the hospital involved must be approved to provide inpatient procedures preliminary to the transplant. The Renal Provides List (furnished to ODO by CMS) should be checked to determine if the hospital is approved. See exhibit DI 45001.110.
* Verify that the “Certification for Self-Care Dialysis Training” on Form CMS-2728-U3 is properly signed and the provider is listed as certified from an updated list of certified providers of self-care dialysis training supplied to ODO by CMS. See DI 45001.015F for processing.
* ODO will retain jurisdiction of all ESRD only claims (i.e., uninsured claims, BIC T). Thus, if the claimant dies before adjudication, the claim will be retained in ODO and processed as a closed period or a denial. Also, see DI 45001.001B and DI 45001.015C.
* When a disabled claimant has ESRD, and application for ESRD Medicare should be developed for all D-HI beneficiaries without exception. An ESRD claim should only be developed from an individual age 65 or over if some benefit can accrue to the person (i.e., retroactive coverage or a premium rollback). In all other cases the field office should not solicit an application and should refer any CMS-2728-U3’s for the beneficiary group to CMS directly. If an CMS-2728-U3 for an age 65 HI beneficiary (who has no advantage from an ESRD claim) is received in ODO without an application refer it to CMS ESRD-MIS Data Processing Center 1-C-15 Oak Meadows Building. Annotate the optional Form-41 “Attached CMS-2728-U3 was received for an insured aged period who is already entitled to Medicare at the base rate.” Do not attach any other forms (i.e., SSA-5002, MBR, etc.) to the CMS-2728-U3/OF-41. If other forms are already attached by the FO, detach them in ODO and destroy them after verifying patient is over age 65 and already entitled to Medicare at base rate. Of course, if an application was obtained, full processing to a proper decision and notification is necessary.
* If the claimant is already a disability beneficiary when the ESRD Medicare claim in received and the claimant has had a kidney transplant, the claim must be forwarded to a disability examiner upon completion of the ESRD Medicare adjudication. An SSA-567 should be used for this purpose. Enter in remarks “Possible CDR, Kidney transplant.”
* Claims properly referred to the BET in accordance with HI 00801.300B will be processed in accordance with DI 45001.015C and DI 45001.055 (for closed period cases). Title II disability determination allowances may be adopted for ESRD Medicare claims. Title II disability disallowances and/or Title XVI determinations may not be adopted for Title XVIII claims.
* For electronic folders, create a barcode coversheet and fax the SSA-892 and CMS-2728 into eView. For paper folders, fax the forms into NDRed (Non-Disability Repository for Evidentiary Document).
F. ODO benefit earnings technician (BET) responsibilities in DOFA cases
* Systems exceptions resulting from FO error are forwarded to the BET for correction. The BET will follow the procedures in DI 45001.005C. Upon correction the BET will send the case to a BA for systems input.
* ESRD disallowances will be reviewed by the BET. If the claim has been properly adjudicated by the FO, the folder will be released through existing procedures or routing instructions on the folder. If the claim was not properly adjudicated by the FO the BET will properly adjudicate the claim (i.e., amend the action) if possible and provide a special notice to the claimant if his/her entitlement is affected of if he/she has not been properly notified. If the claim cannot be properly adjudicated immediately, the BET will take necessary development or referral action. Claims needing additional processing or adjudication will be processed under current operating procedures (i.e., ODO rather than DOFA). Appropriately select and modify the language in the exhibit letters (DI 45001.070).

POMS Reference

DI 45001.005: Processing ESRD Claims