DI 45001.055 Report of Transplant or Cessation of Dialysis After Entitlement
When an ESRD award is made, the patient is advised to notify SSA in the event of a transplant or cessation of regular dialysis without transplant.
A. Report of transplant
If a report of a transplant is received, prepare (as shown in DI 45001.001) and release a Form SSA-1598 to the benefit authorizer. Also, if a DI or an SSI disability claim has been filed, attach a Form SSA-567 to the front of the folder referring the case to a disability examiner after all (immediately required) ESRD actions have been completed. Review the case to determine: a.If the transplant date or the date of hospitalization in anticipation of a transplant would result in an earlier month of Medicare entitlement than previously established based on dialysis and b. What appropriate steps, (including diary and acknowledgement if indicated) must be taken to notify the beneficiary and effect timely termination of Medicare coverage.
If an earlier entitlement date is justified, a revised determination must be prepared, and notification of the revised determination must be sent to the claimant. See DI 45001.095 as well as DI 45010.001. Depending upon the proximity of the COM to the 33rd month after the month of transplant, it may be expedient to consider a closed period to accomplish both the revised determination and the impending termination (see DI 45001.015 C.).
If the 33rd month after the month of transplant is over 30 days in the future and an earlier entitlement date is not justified, send an acknowledgement letter to the claimant. See DI 45001.089 as well as DI 45005.001.
If the report of transplant is received within 60 days after the due date of termination based on the transplant (no new transplant or dialysis before termination date), process as follows:
Do not immediately take any action to terminate the period of entitlement.
Because of the expediency needed for development, develop via telephone. Make a Report of Contact.
Develop (if indicated) for a new CMS-43 for a new period of entitlement and all necessary entitlement information.
If no other HI/SMI entitlement (e.g., D-HI/D-SMI, age 65 HI/SMI) is involved, inform the FO of the urgency of the development and that they should give an indication by telephone within 10 days regarding the following (or else termination action will have to be initiated to prevent higher potential overpayment):
An application will be filed,
SMI is desired,
Dialysis is received at least once/week (HI 00801.302 B.1.a.) or new transplant received,
Insured Status appears to be met, and
All other developed entitlement criteria appears fulfilled.
Diary the case for 10 days for recontact with the FO.
If based on the FO"s telephone response, it appears the claimant will be reentitled, take no action on the entitlement at that time and diary the case for 30 days for receipt or status check on development. If FO cannot respond, take termination action.
If based on the FO"s telephone response, it appears the claimant will not be reentitled, prepare termination action based on the transplant and notice to the claimant.
If the FO developed new claims material, allow or disallow the claim as appropriate upon receipt.
Regardless of whether a new claim is filed and allowed or disallowed, the prior entitlement must be terminated. However, if the new claim is allowed the termination and allowance actions should be taken at the same time to insure uninterrupted coverage if appropriate. Only one notice should be sent to the claimant explaining the termination and subsequent allowance or disallowance actions, provided the termination and subsequent allowance or denial determination actions are taken simultaneously. Prepare a notice using appropriate modifications of existing guide language. Also, see DI 45010.050 for folder maintenance actions for closed period, terminations and disallowances.
NOTE: See DI 45010.010 F. if the report of transplant is the ESRD Kidney Transplant Listing.
B. Report of cessation or interruption of dialysis after the qualifying period
If a cessation of a regular course of dialysis is reported in situations other than a transplant or dialysis interruption of no more than 30 days, prepare a Form SSA-1598 and release it to the benefit authorizer. (Interruption of dialysis of no more than 30 days will have no effect on the beneficiary"s entitlement.) If, in addition to the cessation of a regular course of dialysis:
at least 10 months have elapsed since dialysis ceased, take termination actions per DI 45010.001. (including diary and notification as indicated), or
over 30 days have elapsed but 10 months have not elapsed since dialysis ceased, send an acknowledgement letter (DI 45001.090). If the 10th month after the month dialysis ended is over 30 days in the future, diary the case for the 10th month and then take termination actions indicated per DI 45010.001. If the case will be sent to OD per DI 45001.015 E., do not send an acknowledgement letter pending any instructions from OD. Upon return of the case from OD, send the acknowledgement letter only if CMS has not contacted the claimant and B.1. above does not apply. Diary the case if the 10th month is over 30 days in the future and then take termination actions if indicated per DI 45010.001.
NOTE: If cessation of dialysis is reported and a DI or SSI disability claim has been filed, prepare an SSA-567 to route to a disability examiner after all (immediately required) actions on the ESRD claim have been completed.
C. Report of nonparticipation iIn self-dialysis training, waiver previously approved
Whenever self-care dialysis training has been verified and the claim adjudicated (no conflicting information), pursue no further verification of completion of the training course. This is because if there is a significant increase in patients who fail to self-dialyze, CMS questions the facility"s training program through their certification process. However, CMS will not penalize the Medicare beneficiaries.
Based on the above reasons and for processing (adjudicative) uniformity, once the qualifying period has been waived based on self-dialysis training, the waiver normally is not reversed. (See DI 45001.015F.6.).