TN 31 (06-04)

A. Policy

The CMS-2728-U3 is the primary medical evidence.

B. Procedure — Medical requirements

If dates of dialysis, hospitalization, or transplant alleged on the application are not documented by dates on the CMS-2728-U3, resolve discrepancies as described in HI 00801.233I.

C. Procedure — Review of treatment information

Review the treatment information on CMS-2728-U3 (End Stage Renal Disease Evidence Report Medicare Entitlement and/or Patient Registration Form).

1. Item 24 — Date regular dialysis began

Make sure there is an entry for the date the course of dialysis was initiated if entitlement is alleged based on dialysis.

2. Item 28 — Date of transplant

If no entry is made, check the application form to insure that the claimant does not allege receipt of a transplant.

3. Item 31 — Date of hospitalization

If the patient was in a hospital as an inpatient for procedures preliminary to a transplant surgery, remember that entitlement can begin earlier than the month of transplant (see HI 00801.221).

4. Items 32 and 33 — Name of preparation hospital

In order to establish entitlement based on hospitalization for transplant, make sure the hospital involved is an approved renal transplantation center or renal dialysis center. Check the “Listing of Renal Providers DOFA Process (SSA),” a publication furnished by CMS, to verify that the hospital, identified by name and provider number in items 32 and 33, is approved. The listing can be found on the CMS web site at https://www.medicare.gov/dialysisfacilitycompare/. If the hospital is not on the listing, contact your CMS RO to determine status. If the hospital is not an approved medical facility, do not allow entitlement prior to transplant.

NOTE: An award granting early entitlement may not be made until there is evidence of actual transplant surgery, unless the person dies during transplant surgery. Death during the surgery does not prevent early entitlement based on hospitalization.

5. Item 34 — Current status of transplant

1. “Functioning” - If this block is checked, process a favorable determination.

   EXCEPTION: If the last transplant occurred 33 or more months before the month of adjudication, a closed period of Medicare must be established.

2. Nonfunctioning - Nonfunctioning is defined as that point in time when chronic maintenance dialysis is again initiated. If nonfunctioning is checked, look for a date entered in item 36.

6. Items 38 and 39 — Training provider

Check the “Listing of Renal Providers DOFA Process (SSA)” to verify that the training center identified is approved for this service. The listing can be found on the CMS web site at https://www.medicare.gov/dialysisfacilitycompare/. If the training provider is not on the listing, contact the appropriate CMS RO to determine status. See HI 801.143C. for a list of the CMS regional offices.

7. Item 40— Date training began

Verify that training began prior to the third month after the month in which the regular course of dialysis began.

8. Item 42 — Self-dialysis training

Whenever the claimant alleges participation in a self-care dialysis training program, make sure item 42 is checked “yes” and the physician’s signature is shown in item 44. If it is not completed, develop for it, or list reasons for non-development in the file as described in HI 00801.233I.

If the “no” block is checked, clarify whether it was checked in error. Review this section of the form to determine whether the 3-month qualifying period for entitlement based on dialysis will be waived due to participation in self-dialysis training as discussed in HI 00801.226.

9. Item 43 — Training completion date

Verify that the claimant either has already completed the training program or is expected to complete the program. Do not hold a case pending completion of the qualifying period. Assume that the dialysis will continue unless there is an indication that it will not be maintained. If the claimant dies before completion of the training, consider that waiver may still apply.

NOTE: In order to establish entitlement, the regular course of dialysis must be maintained throughout the time that would otherwise be the qualifying period (unless it is terminated earlier because the patient dies).

10. Item 44 — Physician’s certification of self-care training

Complete this block if a waiver is to be applied. See HI 00801.226 for the date of entitlement based on self-dialysis training.

11. Items 49 and 54 — Physician and patient signatures

Verify that the physician and patient signatures are present. If not, develop for signatures, or list reasons for non-development in the file, i.e., patient deceased.

12. Item 53— Remarks

Consider any entries and their effect on entitlement.