BASIC (05-11)

DI 11052.035 Routing Initial End-Stage Renal Disease Medicare Cases after a Field Office Determination

When a claimant contacts the field office (FO) about filing for ESRD benefits, or the FO receives Centers for Medicare & Medicaid Services (CMS) form CMS-2728 (End-Stage Renal Disease Medical Evidence Report), take the following actions:

A. Make a determination as to whether:

  • The case is ESRD only,

  • There is an existing Certified Electronic Folder (CEF) only, or

  • The number holder (NH) files concurrently for disability benefits (Title II and/or Title XVI) and we establish a CEF in addition to the ESRD claim.

B. If case is ESRD only and there is no CEF,

  • Prepare a barcode fax coversheet to submit forms SSA-892 (End Stage Renal Disease (ESRD) Medicare Determination) and CMS-2728 (End Stage Renal Disease Medical Evidence Report) into the Non Disability Repository for Evidentiary Documents (NDRed), when processing is complete.

  • If PC action is required, create an actionable fax Paperless barcode coversheet, select document type “Claim ESRD PC7-Initial Claim-ESRD PC7/DAC” and the Additional Information “ESRD Claim” and include the SSA-892 and CMS-2728 and fax to PC7 via the Paperless Processing Center (PPC).

  • For adult children age 22-26, filing for ESRD Medicare using a parent’s insured status refer to DI 1102.005E. For CEF exclusions, forward the brown folder under the appropriate routing form to the Office of Disability Operations (PC7), 1500 Woodlawn Drive, Baltimore, MD 21241, when processing is complete.

NOTE: If manual action needed, do not fax forms into NDRed. It is Office Disability Operations (ODO) responsibility.

C. If there is an existing CEF (pending or closed), FO verifies ESRD entitlement and processes the claim.

Additionally, the FO will:

  • Complete the Form SSA-892-U2 (End Stage Renal Disease (ESRD) Medicare Determination) per “Preparing the SSA-892-U2” HI 00801.308.

  • Create a barcode coversheet for Form SSA-892-U2 using document type code 0113-ESRD Medicare Determination.

  • Create a barcode coversheet for Form CMS-2728-U3 using document type code 0114-ESRD Medical Evidence Report.

  • Fax both the SSA-892-U2 and the CMS-2728-U3 into the CEF using the barcode coversheets per “Faxing Documents into the Certified Electronic Folder (CEF) Using Barcodes” DI 81010.090.

  • Prepare and fax Form SSA-3601 Claims Routing Form to PC7 via the Paperless Processing Center (PPC) system using FAX number (877) 385–0643.

    NOTE: This alerts the PC that there is an issue pending; the faxed Form SSA-3601 should display the proper TOEL – “CLAIM ESRDINT” and a remark “Manual Action Required”.

  • Input the adjudicative decision and PC7 jurisdiction on the Decision Input (DECI) screen.

    NOTE: Use Non-Earnings Computation (EC) Clearance when transferring the MCS segment to PC7 for manual processing of the ESRD award.

  • In some cases, a CEF exists for a claimant in a terminated status (e.g., LAF-T8 or X7). If the FO can process the ESRD award action to completion (LAF change to “U”) via MCS EC, skip the fifth bullet shown above, as no PC7 MACADE action is required.

    NOTE: If no PC7 MACADE action is required, scan both SSA-892 and CMS-2728 into NDRed.

    References:


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DI 11052.035 - Routing Initial End-Stage Renal Disease Medicare Cases after a Field Office Determination - 05/03/2016