DI 45001.210 ODO Earnings Reviewer Responsibilities
ESRD Medicare claims in which insured status is based in whole or in part on the federal employee provisions should be first examined to determine if the claimant meets insured status without considering FQC's. (This examination should include a review of the claimant's earnings record as well as the records of his or her spouse and/or parents on whom he or she is dependent.) If insured status is met without considering FQC's, the claim should be processed under regular ESRD procedures. If the claimant does not meet the insured status requirement without federal wages, there is an indication of federal employment in the file, folder is not documented by DO on this issue, forward the claim to a claims authorizer (CA) under cover of an SSA-559. Show in remarks the following:
“ESRD Medicare claim. Please determine if insured status is met using federal employment (see HI 00801.400 through HI 00801.435). If insured status is met using FQC's, advise if any deemed FQC's were used. If insured status is not met using FQC's, please furnish disallowance notice language or identify paragraphs which can be used in the disallowance notice to the claimant.”
Also prepare an SSA-567 to have the folder returned to you after CA actions are complete.
On return of the ESRD folder from the CA, place the CA's response on the right side of the folder if the CA has not already done so, and process as follows.
Prepare an SSA-892-U3 determination as outlined in DI 45001.025. If the claimant is the spouse or dependent child of the insured federal employee, the federal employee's SSN should be displayed in item 4 and his or her name in item 7 of the SSA-892-U3.
Disallowed ESRD claims will be adjudicated on the federal worker's SSN whenever the claim for Medicare was filed based on federal employment as indicated by a covering claims transmittal form annotated in red “Medicare Based on Federal Employment” and/or an SSA-795 (per HI 00801.440B).
If the potentially disallowed claimant based on SSQC's did not specifically file for ESRD Medicare based on federal employment but it is obvious that there was intent to file based on federal employment or that insured status would likely be met based on federal employment at an earlier point than it would be met based on SSQC's, the claim should be adjudicated on the federal worker's SSN.
Disallowance notices will continue to be manually prepared as they are for regular ESRD Medicare claims. As noted above, CA's will provide special language for inclusion in the disallowance notice if insured status is not met using FQC's. The folder should be routed to a typist for preparation and release of the disallowance notice, and then routed to a CA via an SSA-567 for preparation of an SSA-3428-U2 (Determination of Disallowance Coding Sheet).
Allowed ESRD Medicare claims using FQC's for insured status must be adjudicated using the federal worker's SSN.
If an SSA-101-U3 is needed for adjudication, refer to DI 45001.326 for special coding instructions. New BIC's have been established for the federal employee claims and they are listed in SM 00550.010. Entries in item 1 of the SSA-101-U3 will always refer to the federal employee, even if he or she is not the ESRD claimant. Additionally, careful attention should be paid to the completion of the REQ QC, HAS QC and MAR. ST. (TOA) blocks of item 2 and to the coding of the benefit continuity factors in item 7.
Temporary notices of entitlement currently in DI 45001.077 through DI 45001.080 should also be sent to ESRD beneficiaries qualifying under the FQC provisions. The typist should be instructed to use the federal worker's SSN on these letters followed by the appropriate federal Medicare BIC.
Similarly, an HCFA-8063 should be prepared for federal ESRD Medicare awards. Complete the form as outlined in DI 45001.045 with the following modifications:
Annotate the top of the form in red: “Federal Medicare—ESRD Award.”
Enter the federal employee's SSN in spaces 1 through 9 of item 1. This should be followed by the appropriate federal Medicare BIC. (If the BIC contains 3 positions, place the last letter or number to the right of space 11.)
Currently all MADCAP award notices for federal Medicare claims must be manually prepared. NL 00720.180 lists various stock paragraphs which may be requested by the adjudicator and which will be available on the word processor.
Based on information displayed on the award form, the benefit authorizer is responsible for assigning paragraphs relating to premium payment and third-party buy-ins. The earnings reviewer is responsible for assigning the paragraphs listed below. These paragraphs should be displayed under the claims symbol in item 12 of the SSA-101-U3, if space permits, or on an SSA-573. Additionally, they should be sequenced in the order shown below:
MM90: This paragraph with appropriate fill-in should be assigned if the ESRD claimant is a federal employee.
MM91: This paragraph with appropriate fill-ins should be assigned if the ESRD claimant is a spouse or dependent child of a federal employee.
MA01: This paragraph with appropriate fill-ins should be assigned if the proof of birth code in item 6 of the SSA-101-U3 is a “B,” “C,” “F” or “Q.”
MH16: This paragraph with appropriate fill-ins should be shown if the date of entitlement is based on transplant.
MH17: This paragraph should be shown if the date of entitlement is based on dialysis. (If the claimant participated in a self-care dialysis training program and development is currently being taken to determine if the facility is approved, this paragraph should be modified along the lines of the first paragraph in DI 45001.080.)
Equitable Relief: If equitable relief applies, one of the paragraphs listed in DI 45001.060 should be included in the award notice.
MG09: This paragraph should be assigned in all cases.
MG10: This paragraph should be assigned in all initial award situations.
MG20: This paragraph should be assigned in all cases.
The above list is by no means all inclusive. Other preprinted or dictated paragraphs should be assigned as applicable.
It is important for trust fund reimbursement purposes to properly identify any case in which at least one deemed FQC is used to establish insured status. For this reason all ESRD Medicare awards processed with a federal Medicare BIC will be identified by the system as requiring deemed FQC's for insured status unless the FAC code “FI” is displayed in item 7 of the SSA-101-U3. If after adjudication it is determined that the FI FAC code was not used when in fact insured status was based only on FQC's earned after December 1982, then the folder should be referred to a benefit authorizer for appropriate master beneficiary record correction.
Except for those items listed above, ESRD Medicare claims will be adjudicated and handled in accordance with all regular instructions. Conflicts in procedures should be reported to OD, SPB for resolution or clarification via ODO, OSS.