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