Complete the following forms:
SSA-450 Earnings Record Request
SSA-3687-U2 (Determination of Benefit Rights Coding Sheet)
Review and correct all items as required.
If the ESRD patient is entitled to SSI or is a Medicaid recipient, see HI 00815.030 regarding possible coverage under a State buy-in agreement. If buy-in applies, special
coding is required (FAC code PW).
Verify the appropriate coding in the MH field. Coding in this field must be correct
as the system derives the date of entitlement (DOE) from this entry.
Do not enter a Spanish notice request indicator in the CH field.
If applicable, it will be necessary to request the following paragraphs: (1) RM-30
with appropriate fill-in, when copy of notice is to be sent to a third party, (2)
Paragraph listed in DI 45001.355 A. when waiver of qualifying period based on self-care dialysis is denied.
Request the paragraphs on Form SSA-5002. Also check block 3.a. of Form SSA-3293 and
indicate in remarks: “See SSA-5002 in file for additional notice language.”
SSA-5015-U2 (when needed in successful transplant and cessation of dialysis cases).