Basic (03-86)

DI 45001.101 Notification of Equitable Relief—ESRD Termination (Transplant), DOTH is Earlier Than DOTS—Beneficiary Not Notified Timely

The law provides that Medicare coverage, based on kidney disease, will end with the last day of the 36th month after the month in which a kidney transplant is received unless, before that point, a new transplant is received or regular dialysis is begun. Since you received a kidney transplant in    (month/year)   , your Medicare coverage should have ended the last day of   (month/year)   . Your hospital insurance coverage did end the last day of   (month/year)   . However, because we did not end your coverage on time, the law permits your medical insurance coverage to remain in effect through the last day of   (month/year)   .

If you believe that this determination is not correct, you may request that your case be reexamined. If you want this reconsideration, you must request it not later than 60 days from the date you receive this notice you may make your request through any social security office.

Please read the enclosed leaflet for a full explanation of your right to question the determination made on your claim. If you should again begin a course of dialysis or receive a kidney transplant, please contact any social security office about filing a new claim for Medicare coverage.

Enclosure: HCFA-10128