DI 45001: ODO Processing of Initial End-Stage Renal Disease (ESRD) Medicare Cases
TN 1 (07-04)
A. General
Government employment may be used in determining insured status for Medicare entitlement based on ESRD. See HI 00801.400 for instructions in the use of these wage credits. See DI 11052.015 for special instructions regarding government employment and ESRD cases.
B. Case processing
If insured status is met without considering GEQC’s the claim should be processed under regular ESRD procedures in DI 45001.313. If government employment was used to determine whether or not insured status was met, process in accordance with DI 45001.313 with the following additional considerations:
1. Awards
Complete Form SSA-892-U3 as outlined in HI 00801.308. If the claimant is the spouse or dependent child of the insured government employee, the government employee's SSN should be displayed in item 4 and his/her name in item 6. Medicare entitlement will be established on the government employee's SSN followed by the appropriate government Medicare BIC. (See SM 00550.010.) Show “GEQC” in item 39 (this entry will alert the adjudicators to the special SSN entry in item 4.)
ESRD Medicare awards using GEQC's for insured status must be adjudicated using the government worker's SSN. Information for adjudicating ESRD Medicare claims based on government employment is in DI 11052.015.
Prepare Form SSA-101-U3. NEW BICS have been established for government employee claims and they are listed in SM 00550.010. Entries in item 1 of the SSA-101-U3 will always refer to the government employee, even if he/she is not the ESRD claimant. Additionally, careful attention should be paid to the completion of the REQ QC, HAS QC, and MAR. ST. (TOA) blocks of item 2 (TOA code should be “E”.) and to the coding of the benefit continuity factors in item 7.
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The district office is responsible for assigning the paragraphs listed below. These paragraphs should be displayed under the claims symbol in item 12 of the SSA-101-U3, if space permits, or on an SSA-5002. Additionally, they should be sequenced in the order shown below.
MM90:
This paragraph with appropriate fill-in should be assigned if the ESRD claimant is a government employee.
MM91:
This paragraph with appropriate fill-ins should be assigned if the ESRD claimant is a spouse or dependent child of a Federal employee.
MA01:
This paragraph with appropriate fill-ins should be assigned if the proof of birth code in item 6 of the SSA-101-U3 is a “B,” “C,” “F,” or “Q.”
MH16:
This paragraph with appropriate fill-ins should be shown if the date of entitlement is based on transplant.
MH17:
This paragraph should be shown if the date of entitlement is based on dialysis. If the claimant participated in a self-care dialysis training program and development is currently being taken to determine if the facility is approved, this paragraph should be modified as follows: Delete the second sentence and replace with “The beginning date of the coverage does not take into account your participation in self-dialysis training. We will notify you later if your Medicare coverage can begin at an earlier date because of dialysis training.”
MG09:
This paragraph should be assigned in all cases.
MG10:
This paragraph should be assigned in all initial award situations.
MG20:
This paragraph should be assigned in all cases.
Equitable Relief: If equitable relief applies, one of the paragraphs listed in DI 11052.015 should be included in the award notice.
The above list is by no means all-inclusive. It may be necessary to request the paragraphs listed in DI 45001.313 B.5.b.
Awards being made on a claim number which has a three-position BIC must be excluded from EAM. For such cases enter in the “Remarks” section of the SSA-3601: “Route to ODO Benefit Authorizer for processing.”
2. Disallowances
Whenever the claim for ESRD Medicare was filed based on Federal employment as indicated by the submission of an SSA-795 per HI 00801.440 B. along with the HCFA-43, disallowed ESRD claims will be adjudicated on the Federal worker's SSN.
Whenever the claim for ESRD Medicare was filed based on State or local government employment, disallowed ESRD claims will be adjudicated on the State or local worker's SSN.
Follow the procedures in DI 45010.015 for processing the disallowance.