DI 45010.010 Acceptable Evidence of Kidney Transplant for ESRD Medicare Terminations

See HI 00820.030.

The following are specific descriptions of the types of kidney transplant information which are acceptable for use in establishing the date of ESRD Medicare termination:

1. A. 

   CMS-2728-U3 End Stage Renal Disease Medical Evidence Report Medicare Entitlement And/Or Patient Registration see HI 00801.902;

2. B. 

   Statement or letter from the treating physician or transplant surgeon;

3. C. 

   Statement or letter from the transplant hospital;

4. D. 

   CRD (ESRD) Kidney Transplant Beneficiaries Listing, DI 45001.108.

5. E. 

   In addition, a statement, list, or letter from the Medicare Intermediary or a statement from the ESRD beneficiary or from a person acting on his/her behalf (e.g., parent, spouse) may also be used to established the date of R-HI /R-SMI termination but, after diarying for termination, additional verifying evidence as discussed above must be obtained. (See HI 00820.030).

   In each case, the report must show the name and claim number of the beneficiary, and the month and year of transplant and must not be questionable on its face or because of conflict with other information available.

   However, if reports of terminating events are received more than 3 months before the date of termination, it will be necessary to diary the case per DI 45010.015. If the reports are received within 3 months of the scheduled termination date, due process notice and termination action should immediately be prepared per DI 45010.015. Whenever a termination action is taken and there is a related DI or SSI disability claim, such cases should be referred to a disability examiner for review (see DI 45010.030).

6. F. 

   Processing the ESRD Kidney Transplant Beneficiaries Listing

   This listing, commonly referred to as the transplant listing, is used by the Office of Disability Operations (ODO) to verify that the transplant information is already in the ESRD Medicare file and that necessary actions (diary, potential termination, etc.) have been taken. Based on a 1986 survey, the transplant information had already been reported and was in the folder approximately 70 percent of the cases.

   The source information for the transplant listing is the billing records in the Center's for Medicare & Medicaid Services (CMS). Thus, those individuals identified on the transplant listing must already be on the Medicare rolls when the billing is entered into CMS’s systems. Entries are listed once for each transplant received, i.e., a claimant identified on the May transplant listing because of a transplant received in December will not again be identified on the June or later transplant listing unless that claimant receives a subsequent transplant; in which case the claimant would be identified on one later transplant listing.

   The entries on the transplant listing will be in direct numerical sequence and may be broken out by modular responsibility or other criteria. It will be received in the Operations Support Staff (OSS), ODO from the Office of Disability (OD). OSS will distribute the listing to appropriate ODO personnel to insure timely processing.

The module files will be searched to obtain the ESRD Medicare folders for the corresponding SSN’s shown on the transplant listing. If any folders are not in the module files, the transplant listing will be annotated “NIF” (not in file) next to the corresponding SSN, a case control readout will be obtained and the located folders together with the transplant listing and case control readouts will be distributed to the Earnings Review Examiner (ERE). The ERE will determine from MBR"s, internal controls, review of the transplant listing, etc., if the missing folders need to be obtained and/or whether additional action in accordance with DI 45010.015, below, is needed. If the folders are needed, they will be obtained in accordance with existing internal ODO folder association procedures.

The folder will be needed for review by the ERE in all cases except:

1. 1. 

   Review of internal module controls verifies necessary pretermination diary and transplant acknowledgment notice actions have been taken,

2. 2. 

   The only claim involved is a title XVIII claim (T) and the MBR shows a future termination date which corresponds with termination date based on the transplant date,

3. 3. 

   The claimant is deceased and Medicare entitlement has been terminated in the month after the month of transplant or later, or

4. 4. 

   The claimant is (or will be) age 65 prior to the potential termination date and he/she is entitled to title II benefits as an A or HA (primary beneficiary).

If upon review of the folder, the ERE determines the transplant information had not been previously reported, the ERE will take actions in accordance with DI 45010.015. Additionally, the ERE will annotate the diary form (SSA-5015-U2) “based on transplant listing dated (show date shown on top of each page of transplant listing).” Do not file copy of transplant listing in the claims folder. The ERE will annotate “UTL” on the transplant listing next to the corresponding SSN for any folders that must be reviewed but cannot be obtained, and the listing will be returned to ESRD Medicare specialist in OSS for appropriate notification to the Office of Disability.

If actions such as return to dialysis or death development are necessary based on the transplant listing information, the folder should be documented “transplant listing dated (date) shows ("return to dialysis" or "death").” Also, see DI 45001.055 A. to insure all appropriate actions have been taken.