The Form SSA-892-U3 (End-Stage Renal Disease (ESRD) Medicare Determination) is used for end-stage renal disease Medicare cases. It replaces the determination Forms SSA-831-U5, SSA-833-U5, and SSA-899-U2. An exhibit of the SSA-892-U3 is located in DI 45001.111.

The field offices are responsible for placing Form SSA-892-U3 in the folder for all initial ESRD Medicare claims. Field office personnel will complete items 1-18 for all initial claims and completely adjudicate the form for DOFA processed cases.

Since the Office of Disability Operations (ODO) is no longer responsible for 100 percent review of ESRD Medicare claims processed through DOFA, the FO will be entirely responsible for adjudicating, stripping, and proper distribution of the SSA-892-U3 for DOFA processed cases. For non-DOFA cases, the FO will forward the case with the SSA-892-U3 un-stripped and placed on the left side of the folder.

Item 1

This item is reserved for future use. Do not complete at this time.

Item 2

Show the actual month, day, and year of filing of the current application. The only exception to this rule occurs when an earlier filing date is established based on a written (see GN 00204.005, HI 00801.027B.4.) or telephone request for benefits; in which case, the earlier date should be shown. (If there are two or more current applications, show the earliest filing date.)

Item 3

Enter the title, e.g., Mr., Mrs., Ms., name and mailing address of the claimant. If a proper applicant has filed on behalf of the claimant, enter the applicant’s title and name followed by the “for” (or the appropriate legend), and then the claimant’s title and name, and applicant’s mailing address. Enter names exactly as shown on the SSA-450. If two or more proper applicants have filed on behalf of the claimant, the title, name and address entries for the applicant should reflect whichever of the applicants is the preferred payee.

In situations involving an application filed after the patient’s death, show the applicant’s title and name followed by “On behalf of (patient’s title and name) Dec’d.”

Item 4

Show the SSN of the ESRD claimant.

Item 5

Show the telephone number at which the claimant can be reached.

Item 6

Show the number holder for the SSN shown in item 8.

Item 7

Show the claimant’s relationship to the person shown in item 6.

Item 8

Show the SSN on which entitlement is based if it is different from the one shown in item 4, e.g., the claimant’s Medicare entitlement is based on Federal employment or the claimant is already entitled to spouse’s or child’s monthly Social Security benefits.

Item 9

Show the established month, day, and year of birth, e.g., 03/17/38. If the date of birth, has not been proven, use the date of birth by which the claimant is the oldest.

Item 10

Check “A” and/or “B” to identify the prior claims action, if any. However, Black Lung and SSI claims do not require an entry in this block.

When “A” or “B” is checked, “C” must also be completed to identify the type of claim(s) previously filed.

When both “A” and “B” are checked and/or more than one item in C is checked, give a brief explanation in item 15 in non-DOFA cases, and item 39 in DOFA cases. (e.g., ESRD denied 1974, DIB denied 1974, 1978, Age 65 HI allowed 1985).

Item 11

Show all other types of title II claims on which the ESRD claimant is currently entitled and/or on which there is a claim pending.

Item 12

Check “yes” if insured status is based on Railroad Service or if the claimant is also a railroad annuitant. (See HI 00801.011.)

Items 13 &14

Show the SSA field office address and code.

Item 15

ODO employees will not complete this block. FO employees will complete this item to bring special situations to the attention of ODO, e.g., a CDB re-entitlement claim with re-entitlement period dates, a DOFA exclusion case, a claim filed by or on behalf of a homeless individual, etc.

When concurrent claims are filed, the FO should show the current status of the alternate claim(s): “DWB claim on SSN       pending in FO” or “DWB claim on SSN       forwarded (date first claims material was forwarded to the DDS).”

Item 16

Show the FO’s FTS telephone number. If two telephone numbers can be used, show both.

Item 17

The FO representative should only complete this block for initial non-DOFA claims.

Item 18

The FO representative should only complete this block for initial non-DOFA claims. Show the date the FO transmits the SSA-892-U3 to ODO.

Item 19

1. Check A. (the initial box) if:

   1. it is an initial ESRD Medicare claim (allowance or denial),

   2. it is a new claim for Medicare based on ESRD after a prior period of coverage terminated (see 4.c. below).

2. Check the B. (Recon) box if the action is based on a request for reconsideration of an initial determination.

3. Check the C. (Continuing) box if the action is based on an alert or diary. This box should be checked even if the action results in a cessation determination.

4. Check the D. (Other) box if:

   1. the action is based on an appeal higher than a reconsideration,

   2. the action is a reopening at any level,

   3. the action is a subsequent period of entitlement processed at the same time as a cessation,

   4. the action is taken to revise a prior determination, to establish either an earlier date of entitlement, to affirm a prior determination, etc., but the action is not based on a request for a reconsideration.

If “D” is checked write the type of action to the right of block D (e.g., Affirmation, Reversal, etc.). It may be necessary to show more than one type of action, (e.g., an ALJ Reversal).

More than one block in item 19 may be checked, e.g., if 4c above applies, check blocks a and d. Also, specify “term/ent. same month”.

Item 20

Complete this box for all allowances in which entitlement is based on dialysis except continuing entitlement cases. In a no waiting period case, show the dates that would have applied if a qualifying period had been required.

Item 21

Complete this box for all allowances in which entitlement is based on dialysis and there was a prior period of HI entitlement.

Item 22

(Check all that apply)

Box A. should always be checked for allowances and continuation actions. This information is obtained from the Form CMS-2728-U3 item 26 (signed by a physician).

Box B. (dialysis) should be checked also, if the beginning date of entitlement is based on dialysis or if the person began a regular course of dialysis after a transplant (continuing entitlement). This information is also obtained from the CMS-2728-U3

Box C. (transplant) should be checked whenever the claimant has a transplant or transplant surgery and it is a factor of entitlement or (for continuing determination) potential termination.

Item 23

This item is self-explanatory and should be completed for initial claims.

Item 24

Box A. (dialysis) will be checked if the claimant had self-dialysis training, the qualifying period has been waived, and the Renal Provider List (see DI 45001.108) provided by CMS shows the person’s training facility was approved for dialysis training. If the facility is not approved, show “facility not approved” in item 39. Box B. (transplant) will be checked if the claimant’s entitlement date was based on early transplant procedures and the surgery was performed in an approved treating facility as indicated on the Renal Provider List. If the facility is not approved for transplant procedures, show “facility not approved” in item 39. (See HI 00801.221 A.)

Item 25

If the claimant had dialysis, complete this item in accordance with the information in file CMS-2728-U3 and/or narrative). This item must always be completed if item 22B. is marked. Complete this item as follows:

A1.

The “began” date must always be shown.

A2.

The “ended” date will only be shown in a closed period or disallowance.

B.

The interruption of dialysis box will be completed as appropriate. Also, show the beginning and ending dates of the interruption. However, the ending interruption date must be earlier than the “ended” date (if shown) in the preceding block.

C.

Complete the self-dialysis training information as appropriate.

D.

Complete the self-dialysis training information as appropriate.

E.

Show any comments appropriate to dialysis. For example, if an ending date is shown for dialysis because the claimant died, shown “clmt. died (date).”

F.

Complete the medical certification of self-care dialysis if a beginning date of self-dialysis is shown in this item. This information should be obtained from items 27-32 of the Form CMS-2728-U3. If items 27-31 are completed but item 32 is not signed by a physician or if item 31 (the certification box) is not completed, the “no” box should be checked. If the “no” box is checked, the qualifying period cannot be waived.

Item 26

1. Complete to show the date of hospitalization when early transplant entitlement applies. The month shown must be earlier than the month shown in 26B. If development is needed before a decision can be made, write “development taken”. If early transplant entitlement is not involved, leave blank.

2. Complete for all cases in which the claimant received a transplant.

   NOTE: Whenever a date is shown in B., item 22.C. must also be completed.

Item 27

Complete in conjunction with item 26 and/or item 22.C.

1. Complete (an make referral) in all cases in which the claimant is also entitled to disability insurance benefits (DIB).

2. Complete only if no previously adjudicated DIB allowance claim exists.

Item 28

Complete this item whenever the self-care dialysis information is completed in item 25.C. If box “no” is applicable, specify reason in item 39, e.g., “training ended before completed for reasons other than death.”

Item 29

Check “yes” if State buy-in applies effective with any month from the month of entitlement through the month of adjudication. If State buy-in first applies after the month of entitlement, take any additional action necessary to assure that correct information is placed on the master beneficiary record (MBR). If State buy-in does not apply, check “no”. Also, if State buy-in is being developed, check “no”. However, document the folder that the State buy-in is being developed.

Item 30

This item will never be completed for initial award actions. See DI 45010.025 for ODO completion in post-adjudicative situations.

Item 31

This item will never be completed for initial award actions. See DI 45010.030 for ODO completion in post-adjudicative situations.

Item 32

Equitable relief procedures are shown in DI 45001.060 for initial cases and DI 45010.045 for post-entitlement cases.

1. Complete if the date of entitlement to R-SMI is established later than the R-HI entitlement date in accordance with the equitable relief procedures. If appropriate, also complete item 32.C.

2. Complete if the entitlement dates for R-HI and R-SMI are the same of the claimant refuses R-SMI coverage.

3. Complete if R-SMI premium arrearage is 6 months or more and there is no clear election of SMI or SMI entitlement date by the claimant.

Item 33

A1.

Complete for all allowances.

A2.

Complete A2 if the claimant elects SMI.

B.

Complete for closed period of entitlement only.

C.

Complete by showing the date dialysis began or the date of transplant (or hospital admission-early transplant), whichever is the basis for entitlement. When transplant (or early transplant) is the basis for entitlement, the dates shown in A.1. and C. will be the same except when the onset date is more than 12 months before the month of the application (HCFA-43). When dialysis is the basis for entitlement, the onset date will be the same as the entitlement date if the qualifying period is waived because of self-care dialysis (item 28.A.); otherwise, the onset (excluding retroactivity limitations) date will be in the third month before the month of entitlement. When retroactive entitlement restricts the R-HI date of entitlement, show the actual onset date as shown on the CMS-2728-U3 or medical narrative.

Item 34

Complete this item for all disallowances. Check only the box that most realistically describes the situation. For example, if the claimant does not meet insured status and therefore no medical evidence (CMS-2728-U3) was developed, disallow the claim based on lack of insured status (item B.) rather than on no medical certification (item A.).

Item 35

Complete this item as appropriate in accordance with POMS procedures. If post adjudicative development is not needed, show “none.”

Item 36

Complete in accordance with POMS procedure (DI 45001.055).

Item 37

Complete in accordance with POMS procedure (DI 45001.076). If a dictated letter is needed, show “DL”.

Item 38

Complete in accordance with POMS procedure. If a listing number is needed, show the number; otherwise, leave blank.

Item 39

Complete in accordance with POMS procedure. Also complete when (1) situations described in item 15 above exist except that the case should be DOFA processed and/or (2) additional space is required for item 15 non-DOFA remarks.

Items 40 and 41

These items must be completed by the field office personnel for all DOFA claims or by the earnings review examiner or reconsideration examiner for ODO adjudicated claims.

NOTE: All dates on the SSA-892-U3 must be shown in “MM/DD/ YY” format. If the day is unknown, show “XX” in place of “DD” .

Retention of Form SSA-892-U3

For electronic folders, create a barcode coversheet and fax the SSA-892 into eView. For paper folders, fax the SSA-892 into NDRed (Non–Disability Repository for Evidentiary Document).