DI 11052: FO Processing of Initial End-Stage Renal Disease (ESRD) Medicare Cases
BASIC (05-11)
A. Insured status for End-Stage Renal Disease (ESRD) awards based on Railroad Retirement Board (RRB) earnings
Follow the instructions in Development of Claims for insured status based on RRB involvement HI 00801.235G.
B. Determining how to process a RRB ESRD award
1. RRB ESRD premiums
The Centers for Medicare & Medicaid Services (CMS) bills the claimant for ESRD Part B (R-SMI) premiums, even if he or she is receiving a monthly RRB benefit but is not yet entitled to Medicare. The only time CMS does not bill for premiums is if the claimant is already entitled to Medicare under a Railroad Retirement Claim Number (RLCN) or if the Ledger Account File (LAF) code on the Master Beneficiary Record (MBR) is “E”. For processing instructions, see DI 11052.010E. in this section.
2. Determine if Medicare exists under an RLCN
If the claimant meets the requirements for entitlement to ESRD, we must determine whether he or she is currently entitled to Medicare under a RLCN. A claimant will have Medicare under an RLCN only if he or she:
is age 65 or over, or
has received a disability benefit from RRB for 24 months.
A Medicare record is established if an RRB claimant is age 64 and 8 months or in the 20th month of disability.
Secure an MBR and HI/SMI Query Response (HIQR) printouts on the claimant’s own SSN or any other SSN’s involved, such as those indicated in the answer to item 9(c) of the CMS-43 (Application for Health Insurance under Medicare for Individual with Chronic Renal Disease). Review the printouts to determine whether the:
MBR establishes Medicare entitlement under RRB;
HIQR on the RLCN shows Medicare entitlement for the claimant; or
XCN field of the HIQR on the claimant’s SSN shows a cross reference to an RLCN (six or nine digit number preceded by one, two, or three alpha characters, e.g., WA 123456; A 123456789).
C. Process award when a Medicare record not established and LAF not E
If no Medicare record is established and the LAF code on the MBR is not “E”, process an award per the instructions DI 11052.010D.1. in this section. (We establish the claimant’s ESRD under his or her own SSN with a Beneficiary Identification Code (BIC) of “T”.)
D. Process award when a Medicare record is already established under an RLCN
Complete an SSA-892 (End-Stage Renal Disease (ESRD) Medicare Determination) and follow procedures in this subsection.
1. Beneficiary is entitled to HI/SMI on MBR and RRB has jurisdiction of medical insurance, LAF code is not “E”
MANCLR segment to your field office (FO) code to close and lock segment
Prepare an SSA-3601 (Non-CAPS Routing) – Enter in remarks: “Route to Benefit Technical Examiner (BTE) for Processing. Send an SSA-3103 (SSA Certification of Title II Monthly Benefits to RRB for Payment or Adjustment) to RRB”
Enter HI eff. and SMI eff. (only if ESRD dates are more advantageous than dates on MBR)
Indicate appropriate notice (For notice paragraph, see DI 45001.102)
2. Beneficiary is entitled to HI/SMI on MBR and MBR does not indicate RRB has jurisdiction of medical insurance, claimant has Medicare under an RLCN
Do not prepare an A101 (Beneficiary is already on MBR.)
MANCLR segment to your FO code to close and lock segment
Prepare SSA-3601 (Non-CAPS Routing) – Enter in remarks: “Route to Benefit Authorizer (BA) for Processing. Send an SSA-3103 (SSA Certification of Title II Monthly Benefits to RRB for Payment or Adjustment) to RRB”
Enter HI eff. and SMI eff. (only if ESRD dates are more advantageous than dates on MBR)
Indicate appropriate notice (For notice paragraph, see DI 45001.347)
3. No record of claimant on MBR, claimant has Medicare under an RLCN
Prepare an A101 on beneficiary’s own SSN with a BIC of “T”. Indicate RRB has jurisdiction.
Indicate appropriate notices on the report of contact (RPOC) screen and in remarks – “See RPOC for notices.”
On A101 route sheet-- Enter in remarks: “Route to Benefit Authorizer (BA) for Processing. Send an SSA-3103 (SSA Certification of Title II Monthly Benefits to RRB for Payment or Adjustment) to RRB”
Route the SSA-3601 to PC7.
In all cases in which RRB established a Medicare record under an RLCN, the BA in PC7 completes Form 3103 and forwards it to RRB.
E. Process award when the LAF code on the MBR is “E” (RRB has jurisdiction for payment of Title II benefits)
Photocopy the memorandum in Notice to RRB HI 00801.325: ESRD Medicare Award-LAF Code on MBR is “E”-Exhibit. Complete the requested items. Send original memorandum to RRB and place a copy in claims folder as documentation.
Annotate the appropriate notice on RPOC per DI 45001.348, Notice – R-HI/R-SMI Award when RRB Jurisdiction Involved – LAF Code “E” Cases.
Route the SSA-3601 to the Office of Disability Operations (ODO).