DI 45005.005 Processing Medicare End-Stage Renal Disease (ESRD) Hearing Cases
ALJ’s in SSA’s OHO have jurisdiction for hearings requested on adverse ESRD Medicare
entitlement determinations — denials, cessation, and onset. The FO is the control
point for obtaining and associating the folder with the request for hearing and forwarding
all pertinent material to the appropriate hearing office where the case will be assigned
to an ALJ. General guidelines for hearings cases pertinent to ESRD Medicare claims
may be found in DI 11052.045.
SSA’s OHO is under certain time constraints to issue hearing decisions. These time
limits are measured from the date the request for hearing is filed. Therefore, all
actions taken on the case prior to forwarding it to OHO should be expedited and flagged
for priority handling.
The ODO reconsideration examiner, in preparing the ESRD and any related monthly benefit
claims folders for referral to the hearing office, via the FO, should ascertain whether
there is new evidence, or clear indications in the old evidence, showing that the
reconsideration determination was incorrect. If so, and a totally favorable action
is now possible, reopen the reconsideration determination being guided by the basic
procedures in DI 45001.001 or DI 45010.001, as well as in DI 45005.001. In proceeding with a favorable (revised) determination, also take the following
Send two copies of the notice or award certificate to the ALJ and a copy to the DO.
If in reviewing the folders for referral to the ALJ, via the DO, equivocal medical
evidence is found which might likely be resolved (by CMS"s Medical Officer for ESRD
via telephone discussion with the treating source, et. al.) totally in favor of the
appellant, refer the folder first (with all material) requesting priority handling,
to CMS, BERC, OEP, DMEP, Medicare Entitlement Branch, Room 349 East High Rise under
cover of an SSA-559. These cases should be routed to CMS via OD, SPB, 3-M-25 Operations
Show in Remarks: “ESRD Hearing Request. Please provide medical review. If the reconsideration determination
should be reopened and revised to an allowance (or continuance), return the folder
to (designate the Mod component) reconsideration examiner. Otherwise, forward the
folder to the appropriate field office and notify ODO Case Control of the new folder
location. Do not hold case for more than 60 days.” If the reconsideration determination was clearly an appropriate denial or cessation,
ODO will forward the folder directly to the district office.
Once a favorable hearings or appeals decision is rendered, the claim file should be
returned to ODO for effectuation and processing. The reconsideration examiner is responsible
for all aspects of the determination, although advice and/or nonmedical decisions
and forms preparations may be obtained as required from authorizers, earnings reviewers,
etc. Follow the guidelines in sections DI 45001.025, DI
45005.001, and DI 45010.001, modifying the SSA-892-U3, notices, etc. to reflect the correct level of appeal.
If the file contains unclear or irreconcilable conflicts, ODO should forward the claim
on a high priority, e.g., special messenger, basis to CMS via OD, SPB, 3-M-25 Operations