BASIC (05-11)

DI 11052.030 Adjudication of Initial End-Stage Renal Disease Medicare Cases

District Office Final Authorization (DOFA) applies to all initial ESRD Medicare (hospital insurance (R-HI) and Supplementary Medical Insurance (RSMI) awards and disallowances except when:

  • We need a determination of disability prior to age 22 for a dependent child (see District Office Final Authorization (DOFA) of ESRD Medicare Awards and Disallowances HI 00801.300),

  • We award a closed period of R-HI, or

  • An award or denial is prepared for a reconsideration, administrative law judge, Appeals Council, or court decision.

Prior to adjudication, fax all documentation into an existing Certified Electronic Folder (CEF). If there is no CEF, see DI 11052.035 for instructions.

A. ESRD patient currently entitled to Medicare

We must develop an application for ESRD Medicare (CMS-43) for all Disability (D-HI) beneficiaries. This is required because R-HI may continue after D-HI terminates. If retroactivity is involved, R-HI may even begin earlier.

Develop an application for ESRD Medicare from a beneficiary already entitled to Medicare based on age 65 only if:

  • The beneficiary is not currently enrolled in SMI;

  • The beneficiary is paying an increased premium due to late enrollment;

  • Entitlement to R-HI/R-SMI would be earlier than entitlement based on age 65; or

  • The beneficiary is entitled to premium-HI and/or SMI only.

If the beneficiary is age 65 or over and there is no advantage in filing for R-HI, destroy the CMS-2728, ESRD Medical Evidence Report Medicare Entitlement and/or Patient Registration.

B. Claimant exists on active MBR (LAF=C, D, S, or U) with BIC other than M

We establish ESRD Medicare entitlement on the record on which the beneficiary is currently entitled, and deduct (SMI) premiums from the monthly benefit amount payable. Centers for Medicare & Medicaid Services (CMS) also bills for premiums under the same number when a person is not currently receiving a monthly payment because of Workers’ Compensation/Public Disability Benefit (WC/PDB) offset, or other nonpayment status. If the Railroad Retirement Board (RRB) has jurisdiction of monthly SSA benefits see, Processing End-Stage Renal Disease (ESRD) Medicare Claims with Railroad Retirement Board (RRB) Involvement DI 11052.010.

The following workflow is designed to get the ESRD claim on PC7's WMI list and to get DOWR credit for the field office.

  1. When the claim is ready to clear, complete and transmit the DECI. Change the PC code if PC7 is not the PC shown. 

  2. On the earnings comp request screen, say YES to adjudicate.

    • If the DAPP screen comes up, answer NO to the Adjudication question.

    • If you get a proc lim or exception, PF3 out.

  3. Go to the interface (INTE) screen and overkey the BIC A to BIC T and Proc code "A".

  4. This brings you to the M101 screen; PF3 to return to the INTE screen and overtype the Proc code to "N"  (if you get a red line remark “RECORD NIF on A101 CNTRL” you can ignore it).

  5. Prepare form SSA-3601 for PC7 marked Initial Claim, Non-MCS, ESRD, Unprocessed. For required and conditional remarks see DI 11052.020F.

  6. Fax the SSA 3601 into PC7 Paperless.

  7. Route the claims material according to the instructions in DI 11052.035.

C. Claimant insured on own Social Security Number (SSN)—no active MBR

The Modernized Claims System/Earnings Computation (MCS/EC) processes an award or denial for a person filing for ESRD on his or her own record unless prior entitlement affects current insured status.

  • Run a pre-adjudicative EC in the MCS to review edits or alerts that may affect processing. In addition, query the Earnings Alert system (EARQ).

  • Input an allowance or a denial decision on the Decision Input (DECI) screen in MCS and establish any needed diaries.

  • Overkey the PC JURIS field to PC7 if necessary.

  • Document appropriate notices on NOT3 screen.

  • Process case through MCS/EC or A101 if adjudicative edit results from EC processing.

D. Claimant insured on spouse’s or parent’s SSN—no active MBR

Establish an ESRD claim on the claimant’s own SSN in MCS.

  • On the ESRD screen in MCS, enter the SSN of the spouse or parent insured status is based upon.

  • For a spouse, also enter his or her SSN on the Number Holder Marriage (NMAR) screen. (EC determines insured status for the spouse or parent only when the SSN appears on the appropriate screens.)

  • Input an allowance or a denial decision on the DECI screen in MCS and establish any needed diaries.

  • Overkey the PC JURIS field to PC7 if necessary.

  • Document appropriate notices on NOT3 screen.

  • Prepare an A101 when an EC processing limitation results for these claims.

  • Prepare form SSA 3601 for PC7 marked Initial Claim, Non-MCS, ESRD, Unprocessed. For required and conditional remarks see DI 11052.020F.

E. Concurrent claims

EC does not have the capability to process concurrent claims at the same time. Use the following steps to process concurrent claims.

1. Concurrent ESRD and Disability Claim

Establish and transfer DIB EDCS
Trigger ESRD claim thru MCS (or an A101, if unable to process through MCS)

2. ESRD and RIB Claim

Trigger ESRD thru MCS.  The next day, trigger the RIB claim.
If the ESRD claim won't trigger thru MCS, trigger the RIB claim.  Then process according to the instructions in DI 11052.030B in this section.

3. DIB 090 denial /RIB/ESRD

Deny DIB 090, 
Process ESRD claim thru EC, 
Trigger RIB Allowance.  If processed out of order, it results in additional actions and longer processing times.

4. ESRD, RIB & DIB Claim

Establish and transfer DIB EDCS.
Trigger ESRD claim thru MCS.  If the ESRD claim won't trigger thru MCS, trigger the RIB claim.  Then process according to the instructions in DI 11052.030B in this section.
Trigger RIB claim (the next day)

IMPORTANT: If you process a non-medical completion (NMC) for the DIB claim before you trigger the RIB claim, the DIB claim DECI screen will lock up and the DIB claim will have to be manclrd and reloaded when the decision is received.

5. ESRD and CDB Claim

Establish and transfer CDB EDCS
Trigger ESRD claim thru MCS (or an A101, if unable to process through MCS)

6. ESRD Child, SUR/AUX Child Claim

Trigger ESRD claim thru MCS
If the ESRD claim won't trigger thru MCS, trigger the aux/sur child claim.  Then process according to the instructions in DI 11052.030B in this section.

7. ESRD and DWB Claim

Establish and transfer DWB EDCS
Trigger ESRD claim thru MCS (or an A101, if unable to process through MCS)

8. Hearing Pending on DIB - Claimant files for ESRD

Take ESRD claim on paper
Fax all documents into EDCS
Prepare and Process an EF101

F. Procedure for ESRD patient currently entitled to Medicare as an age 65 or over “M” claimant (SMI only or premium HI and SMI)

ESRD insured status requirements must be met.

  1. Obtain CMS-43 on the claimant’s own SSN.

  2. Complete Form SSA-892.

  3. Prepare an A101 on the claimant’s own SSN with a BIC of “T”.

    • Enter the earlier of (1) the month of entitlement to ESRD Medicare or (2) the premium HI DOE as the HI entitlement date

    • Enter the earlier of (1) the month of entitlement to SMI under the BIC “M” or (2) the ESRD Medicare as the SMI entitlement date

    • Enter “See SSA-5002 in file for notice” in the remarks section. Determine appropriate notice

    • If a beneficiary had premium HI, enter in remarks “Note to BTE: Beneficiary entitled to free HI effective _______. (MOE to R-HI).”

  4. Prepare a diary, if necessary.

    Prepare form SSA 3601 for PC7 marked Initial Claim, Non-MCS, ESRD, Unprocessed. For required and conditional remarks see DI 11052.020F.

NOTE: If we based insured status on Medicare Qualified Government Employment (MQGE) wages, use Beneficiary Identification Codes (BIC) TA on A101.

Reference:

HI 00801.440, Special Rules Applicable to MQGE Claims

G. Disallowances

EC triggers and releases the proper notice for the following disallowance codes. EC also triggers denial code 109 (other health insurance disallowance reason); however, you must include a paragraph explaining the reason for the disallowance on the Notice 3 (NOT3) screen in MCS. Refer to Notice 3 (NOT3) MSOM MCS 009.010.

ESRD related denial codes:

DENIAL CODESREASON

105

Convicted of a crime against the security of the U.S.

109

Other health insurance disallowance action (show in “remarks”).

110

Not insured for HI – use to disallow T claims.

If the denial does not trigger through MCS, take the following actions:

  • Manually clear (MANCLR) the claim to your own FO code to lock the segment;

  • Input a denial via MACADE (show PC7 jurisdiction).


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0411052030
DI 11052.030 - Adjudication of Initial End-Stage Renal Disease Medicare Cases - 01/04/2016
Batch run: 01/04/2016
Rev:01/04/2016