Program Operations Manual System (POMS)
DI 45010.015 Diarying and Processing of Postentitlement Cases Following Notice of Transplant or Cessation of Dialysis
When an ESRD award is made, the beneficiary is advised to notify SSA if he /she receives a transplant or ceases regular dialysis. If notice of a transplant (or of a new transplant if entitlement is already based on a transplant) is received, review the case and take the following actions. If the transplant date or the hospitalization for transplant in a month prior to the month of actual transplant would result in an earlier month of Medicare entitlement than previously established based on dialysis, a revised determination must be prepared. Whether or not an earlier entitlement date would be justified, prepare an SSA-1598 (per DI 45010.040) and diary the case (see “GN 01040.010B., Diary Codes” for the appropriate diary code) for due process and termination of entitlement action as follows. Complete the SSA-892-U3 in revised determinations. Prepare an SSA-5015-U2 under code 2-C-67 for diary purposes. Diary for call-up on the first day of the 33rd month following the month of transplant unless the 33rd month is within 30 days of the current operating month; in that event, take immediate due process and termination action without preparing a diary. On the SSA-5015-U2, enter “ESRD” after the reexam date.
Cases in which notice of cessation of dialysis (other than interruptions of no more than 30 days) is received must also have an SSA-1598 prepared and be similarly diaried. Diary these cases (when transplant is not involved) for call-up on the first day of the 10th month following the month dialysis ended unless the 10th month is within 30 days of the current operating month; in that event, take immediate due process and termination actions. See B. below, DI 45010.030 and DI 45010.040.
Immediately acknowledge receipt of reports of termination events or prepare due process notice of impending termination because of the nearness of the scheduled termination date. Take the appropriate action from the following guidelines and as the case situation may indicate:
For acknowledgement of a report of a transplant (or a new transplant following a prior transplant) when the 33rd month after the month of (the last) transplant is sufficiently in the future to require diary and preclude taking immediate termination action, the language in DI 45001.089 is suggested.
For acknowledgement of a report of dialysis cessation without transplant prior to the 10th month after the month dialysis ceased, the language in DI 45001.090 is suggested and diary for the 10th month.
For combined notification to the beneficiary of imminent Medicare termination (due process) and request for updated medical evidence, following normal diary maturity (10th month after the month dialysis ended or 33rd month after the month of transplant), the language in DI 45001.091 (Dialysis Ended) or DI 45001.092 (Transplant Received) is suggested.
At diary maturity, or when there was no diary and the beneficiary must now be notified of imminent termination (due process), prepare the termination action in accordance with DI 45010.030 as well as the due process notice. Keep in mind that such termination action must be taken before the effective date to prevent incorrect program payments. Few cases will involve a change (a new transplant or course of dialysis) in medical status which is first reported to us following due process notification. Therefore, it is more practical to later amend the determination to terminate and process a continuance then to await the response and then terminate (perhaps tardily).
Whenever a termination action is taken and there is a related DI or SSI disability claim, such cases should be referred to a disability examiner for review (see DI 45010.030).
See DI 45010.050 for diary and folder maintenance instructions for termination actions.
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DI 45010.015 - Diarying and Processing of Postentitlement Cases Following Notice of Transplant or Cessation of Dialysis - 07/30/2008
Batch run: 01/27/2009