BASIC (05-11)

DI 11052.005 Developing Initial End-Stage Renal Disease Medicare Cases

A. Obtain the form CMS-2728 (End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration)

The Centers for Medicare & Medicaid Services (CMS) form CMS-2728 is not an application for end-stage renal disease (ESRD). When the field office (FO) receives a CMS-2728, you must determine the beneficiary’s current Medicare status prior to taking the claim and before the FO forwards the CMS-2728 and other documentation to the Office of Disability Operations (PC7).

  • If the FO receives the CMS-2728 directly from the dialysis facility before the ESRD claimant files an application, attempt to contact the claimant or the appropriate applicant to complete an application. If contact is unsuccessful, prepare a 6-month close out notice using the receipt date of the CMS-2728 as the protective filing date.

  • If the FO receives a CMS-43, Application for Health Insurance Benefits under Medicare for Individual with Chronic Renal Disease, with no CMS-2728, contact the ESRD facility to obtain the CMS-2728. You may need to contact the claimant to obtain information about the facility. Refer to HI 00801.233 for rules on when a photocopy of the form CMS-2728 may be acceptable.

References

  • HI 00801.233, Medical Evidence of ESRD – Form CMS-2728-U3

  • HI 00801.302, Medical Review of ESRD Claims

  • HI 00801.902, CMS-2728-U3, End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration-Exhibit

B. Obtain a completed ESRD claim

Obtain a completed claim for ESRD Medicare either by completing one electronically via the Modernized Claims System (MCS) on the beneficiary’s own Social Security number (SSN) or by completing a paper CMS-43 (Application for Health Insurance Benefits under Medicare for Individual with Chronic Renal Disease or MCS claim). If you use a paper CMS-43, enter it into MCS immediately.

NOTE: You will always establish the claim using the beneficiary's own account number (BOAN) of the ESRD applicant even if he or she is not insured on his or her own record.

Following are ESRD-specific inputs for these MCS application screens:

  • APPL (MSOM MCS 005.009):

    CLAIM TYPE: 8 (ESRD) applies to all claimants filing for ESRD whether based on their own insured status or based on the insured status of a parent or spouse.

  • IDEN (MSOM MCS 005.059):

    DISABLED IN LAST 14 MONTHS - If the claim is for ESRD only, answer N. If the claimant is also filing a disability claim, answer Y.

  • IDN2 (MSOM MCS 005.060):

    Cross-reference SSN: enter the claim number if the number holder (NH) is currently entitled on another SSN.

  • ADDB (MSOM MCS 005.012):

    WILL MEDICARE APPLY: for all ESRD claims, you must answer this question with either 1-YES or 3-ALREADY ENROLLED ON ANOTHER SSN. If you answer 2-NO, MCS generates the following inter-screen edit:

    “INVALID ENTRY- WILL MEDICARE APPLY (ADDB) MUST BE 1 OR 3 FOR THIS CLAIM TYPE, CLAIM TYPE = ESRD.”

  • NMAR: (MSOM MCS 005.037):

    If the claimant is filing for ESRD based on his or her spouse’s insured status, enter the spouse’s date of birth on this screen. MCS generates the following inter-screen edit when the date of birth is missing:

    “BIRTHDATE (NMAR) MUST CONTAIN DATA IF FILING ON SSN OF SPOUSE (ESRD.)”

  • HIKD (MSOM ICD 003.005):

    This screen collects information about kidney dialysis and kidney transplant. You must complete this screen to process an allowance. You must resolve any discrepancies in dates provided by the NH’s allegation and the information found on the CMS-2728.

    Only complete the section(s) that apply. You can establish a dialysis record, a transplant record, or both, as applicable.

    NOTE: The form CMS-2728 provides start and stop dates for dialysis, transplant, and self-dialysis that you will need to complete the HIKD screen:

  • ESRD (MSOM MCS 005.029):

    This screen captures ESRD filing information.

    FILING ON SSN OF:

    Complete this section if the claimant is not insured and filing under the insured status of a spouse, father, or mother. An MCS Earnings Computation (EC) processing limitation results, which requires the FO to prepare an A101.

  • HIHI (MSOM ICD 003.002):

    This screen captures Medicare enrollment data.

CAUTION: See DI 11052.001G if claimant has Group Health Plan (GHP) coverage.

IMPORTANT: R-SMI rather than ESRD Medicare Part A (R-HI) covers most of the dialysis expenses ESRD patients incur. If the beneficiary gains something by refusing R-SMI, he or she should probably postpone filing for R-HI, as discussed in HI 00801.191D.3. If an R-HI claimant elects to decline R-SMI, explain the effects of such a decision and document the case file to show that the claimant understands the consequences of his or her action before awarding R-HI. Pages 13 and 14 of the CMS pamphlet, Medicare Coverage of Kidney Dialysis and Kidney Transplant Services (CMS–10128), explain (in easy to understand terms) GHP coverage and the requirement to have R-HI at the time of transplant in order for payment of immunosuppressive drugs.

TYPE OF ACTION: Enter to enroll in or refuse ESRD Medicare Part B (R-SMI). Other options also available are to withdraw, cancel withdrawal, or waive equitable relief. Options 1 and 2 are the most common at the initial claim level.

EQUITABLE RELIEF REQUESTED (Y/N):

Enter “Y” if you make an entry in the SMI OPTION field at the bottom of the screen.

ESRD OPTIONS:

If there are more than 6 months of retroactive entitlement to R-HI, the beneficiary can elect R-SMI effective: the first month of R-HI, the month of filing, or the month of processing.

BENEFICIARY RESTRICTED HI ENTITLEMENT MONTH (MMYY):

This field is optional. Enter the calendar month and year HI entitlement is to begin for premium-free HI.

SELECT SMI OPTION ONLY IF PROCESSING DATE IS MORE THAN 5 MONTHS AFTER THE FIRST POSSIBLE MONTH OF ENTITLEMENT- SMI OPTION: Complete this section only if the claimant does not want to (or is unable to) pay premiums back to original date of entitlement

Your choices are application month or processing month.

Because a NH awarded R-HI retroactively may have difficulty paying the R-SMI premium arrearage, SSA will allow the NH to choose his or her R-SMI entitlement month. Equitable Relief provisions apply to an R-SMI premium arrearage of six months or more of R-SMI coverage. If you enter a SMI entitlement month, refer to DI 11052.030C to determine if you also enter “Y” in the EQUITABLE RELIEF REQUESTED field.

  • DECI (MSOM MCS 009.013):

    PC7 has jurisdiction of all ESRD claims. Overkey the PC JURIS field if necessary.

NOTE: Process ESRD applications by attestation per GN 00201.015, Alternative Signature Methods.

Reference

HI 00801.248, Effect of Immunosuppressive Drug Coverage on Filing for R-HI and R-SMI

C. Obtain proof of age (POA)

POA is required whenever attainment of age 22 or 62 affects fully insured status of an insured number holder who does not have 40 quarters of coverage. The FO should obtain POA following the usual POA guidelines in Tolerances for Developing Evidence of Age GN 00302.030. In addition, if claimant is a child, POA is required to determine dependency point as explained in DI 11052.005D.

References

D. Evidence of relationship and dependency

Apply the same relationship requirements (except as noted below) and require the same proofs as if the claimant is filing for monthly benefits on the NH’s earnings record. HI 00801.201.C. explains the relationship and dependency requirements in detail.

  1. If an ESRD patient who is ineligible for Medicare because he or she is uninsured, marries a Retirement Survivors Disability Insurance (RSDI) beneficiary or a person who is fully or currently insured, the insured status requirement is met as of the first day of the month of marriage.

  2. A dependent child for purposes of R-HI is an ESRD patient who is unmarried, and meets the relationship requirements for child's insurance benefits on the SSN of a NH:

    • at or after the onset of ESRD, or

    • at the time the NH died (if the NH is deceased).

In addition, at the time of ESRD onset the ESRD patient must meet either of the following dependency requirements:

  • is under age 22 or is under a disability which began before attainment of age 22; or

  • has attained age 22, but has not attained age 26, and

  • is receiving at least one-half support from the NH; and

  • has received such support continuously since the day before attainment of age 22. (Temporary interruptions such as a stay in a hospital or a visit with a relative do not prevent the claimant from meeting this requirement.)

E. Over age 22 and disabled requiring a disability determination

It is not necessary for a claimant to be entitled or eligible for disability benefits in order to qualify as a dependent disabled child for ESRD Medicare benefits. However, the Disability Determination Services (DDS) must make a determination as to disability prior to age 22.

If dependency prior to age 26 cannot be established,

  • Obtain an SSA-3368, one SSA-827, and available medical evidence.

  • If Certified Electronic File (CEF) exists, fax all materials into the CEF. If there is no CEF, place all materials into a brown folder.

  • Process via A101 according to instructions in DI 11052.030

  • Forward case to the DDS.

F. Consider retroactivity

ESRD cases are eligible for up to 12 months retroactivity. This could result in possible premium arrearage. Consider this when determining entitlement dates for R-HI and R-SMI. DI 11052.020A.1. discusses how to handle premium arrearage.

G. Prepare Form SSA-892 (End-Stage Renal Disease (ESRD) Medicare Determination)

Complete an SSA-892 in all cases prior to adjudicating the claim and releasing the notice of determination. HI 00801.308 explains how to complete this form.

References:

  • HI 00801.196, Application Requirement

  • HI 00801.235, Development of Claims

  • HI 00801.308, Form SSA-892-U2 (End-Stage Renal Disease (ESRD) Medicare Determination)

  • OS 15020.195, SSA-892-U2 (End-Stage Renal Disease (ESRD) Medicare Determination) - Exhibit


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DI 11052.005 - Developing Initial End-Stage Renal Disease Medicare Cases - 12/08/2014
Batch run: 12/08/2014
Rev:12/08/2014