TN 31 (06-04)

A. Introduction

The Form CMS-2728-U3 (End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration) is the primary documentation that a claimant has ESRD. It also provides statistical data for use in monitoring the ESRD program.

B. Description of CMS-2728-U3

The CMS-2728-U3 is a two-page, three part snap-out form with copies for the:

• SSA claims folder (blue original);

• ESRD Network (green copy); and

• patient's medical records file (provider's white copy).

Dialysis information is contained in items 20-27, transplant information in items 28-37, and self-dialysis training information in items 38-43.

NOTE: See HI 00801.233H. for an explanation of when field offices can accept a photocopy of the form CMS-2728-U3.

C. Description of electronic CMS-2728-U3

The electronic version of the form CMS-2728-U3 enables ESRD facilities to automate the collection and transmission of medical evidence for individuals with ESRD and will eventually replace the paper form. Field offices will receive computer printouts of the form CMS-2728-U3 instead of the blue copy. The electronic form contains the same data in the same format as the paper form and will be signed by the attending physician in blue ink. This version of the CMS-2728 is acceptable as medical evidence of ESRD and should be processed like the blue copy.

D. Process - Facility

The CMS-2728-U3 is completed and signed at the facility when a patient is diagnosed as having ESRD and has begun a regular course of dialysis or received a kidney transplant. The CMS-2728-U3 is completed and required signatures are obtained at the facility.

If the patient is filing for Medicare, the facility sends the blue copy (or the white electronic version) of the form to the SSA field office (FO). The facility sends the green copy of the form to the designated ESRD Network of which that facility is a member.

E. Process - ESRD network

Upon receipt of a CMS-2728-U3 for a person filing for Medicare, the ESRD Network enters the information on the form through the Standard Information Management Systems (SIMS). Information contained on the CMS-2728-U3 will be evaluated using profile analysis and if any pattern of program abuse is observed, the information will be forwarded to CMS for resolution.

F. Procedure (FO) - Patient not filing for Medicare

Return the form CMS-2728-U3 to the facility in either of the following situations:

• Item 11. of the CMS-2728-U3 (Is Patient Applying for ESRD Medicare Coverage?) is checked “No”; or

• Item 11. is checked “yes,” but it is subsequently discovered the patient does not currently wish to file for R-HI because he/she has group health plan coverage and Medicare will be the secondary payer of benefits during the ESRD coordination period. See HI 00801.247 for the policy on ESRD benefits when a secondary payer is involved.

G. Procedure (FO) - Patient already entitled to Medicare

When a form CMS-2728-U3 is received for an individual who is already entitled to Medicare based on ESRD, and one of the following situations apply, deemed reentitlement to R-HI applies and the individual begins a new IEP for R-SMI.

NOTE: If deemed reentitlement to R-HI does not apply, destroy the CMS-2728-U3.

1. Policy – Dialysis resumed or new transplant received in period prior to termination

When an individual has a transplant, Medicare entitlement terminates at the end of the 36th month after the month of transplant. When a course of renal dialysis ends, Medicare entitlement terminates at the end of the 12th month after the last month of dialysis.

If a subsequent CMS-2728-U3 reflects that, prior to the termination date for either of these occurrences:

• an individual who previously had a transplant,

• or who stopped a regular course of dialysis treatments,

has initiated or returned to a regular course of dialysis or has received another transplant, entitlement to R-HI is deemed to begin again under the law (even though, in fact, it has not yet ended).

2. Policy – Deemed reentitlement to R-HI and new IEP for R-SMI

When deemed reentitlement to R-HI applies, a new initial enrollment period (IEP) for R-SMI begins. If the individual is entitled to R-SMI when the dialysis begins or resumes, or another kidney transplant is received, the entitlement continues, just as the R-HI entitlement is actually continuing. However, an individual who:

• has never enrolled in R-SMI, or

• had previously terminated R-SMI (or had R-SMI terminated for non-payment of premiums)

can, upon deemed reentitlement to R-HI, be enrolled in R-SMI under the same conditions described in HI 00801.251, i.e., he or she is treated as if he or she was coming onto the R-HI rolls for the first time. The enrollment form is the CMS-40B or any signed statement by the beneficiary or his or her representative. There is no premium surcharge for late enrollment during the new R-SMI IEP, even if one had previously been in effect.

3. Example

Ray had a transplant in 8/98. His Medicare entitlement was going to terminate effective 8/31/01. He voluntarily terminated his R-SMI in 2 /00. In 6/01, he began a regular course of dialysis because his transplant failed.

Ray's expected R-HI termination does not occur. Instead, he is deemed reentitled to R-HI effective 6/1/01. He is, therefore, able to enroll in R-SMI effective with that month. If a premium arrearage of 6 months or more is involved, he may have the choices of R-SMI entitlement dates described in HI 00801.251B.

H. Procedure (FO) - Patient filing for Medicare

The attending physician’s CMS-2728 attestation should be accepted as proof of ESRD and the claim can be processed as soon as all entitlement issues have been resolved. Award R-HI the earliest possible date (unless the claimant requests a later date) using the dialysis/transplant information on the CMS-2728-U3.

NOTE: In cases where the original form CMS-2728-U3 was returned to the facility because the patient did not file an application, and the individual later decides to file based on the same medical evidence, the physician who is currently following the patient will re-sign and date the original CMS-2728-U3 in the remarks section and send a photocopy to the FO. A new CMS-2728-U3 will only be completed if the facility cannot locate the original form.

I. Procedure (FO) - Discrepant dates

If the dates of dialysis, early transplant procedures, transplant, or self-dialysis training given by the patient on the CMS-43/MCS application differ from those on the CMS-2728-U3 completed by the facility and could affect the date of R-HI entitlement, resolve discrepancies by contacting the patient and/or facility, as appropriate. If the dates shown on the CMS-2728-U3 are found to be correct, document the file with a Report of Contact and process the claim.

If the date(s) on the CMS-2728-U3 are incorrect or missing, make a photocopy of the CMS-2728-U3 for the file and return the original blue copy to the facility for correction. Follow up in two weeks, if the corrected copy has not been received.

If a response is still not received, and there is no question that treatment was received at least as early as the date(s) documented on the existing CMS-2728-U3, and these dates(s) permit immediate entitlement, establish R-HI entitlement based on the available information.

If the corrected CMS-2728-U3 is received after adjudication, forward it to ODO, 1500 Woodlawn Drive, Baltimore, MD 21241.