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

  1. 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.

  2. 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.).

  3. 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.

  4. 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:

    1. Do not immediately take any action to terminate the period of entitlement.

    2. Because of the expediency needed for development, develop via telephone. Make a Report of Contact.

    3. Develop (if indicated) for a new CMS-43 for a new period of entitlement and all necessary entitlement information.

    4. 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.

    5. Diary the case for 10 days for recontact with the FO.

    6. 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.

    7. 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.

    8. If the FO developed new claims material, allow or disallow the claim as appropriate upon receipt.

    9. 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 tr