DI 45010.030 ESRD Medicare Termination Action—Completion of SSA-892-U3
A. How to prepare SSA-892-U3
If termination of entitlement is appropriate, prepare an SSA-892-U3 as follows:
Complete items 1-14, and 16.
Check item 19, block C. If appropriate, also complete block D per DI 45001.025.
Complete item 25, block A or item 26, block B according to whether entitlement has ended based on last date of dialysis or date of successful transplant.
Complete item 31, block A and/or B, as appropriate. If entitlement terminated due to a successful transplant, always check item 26 B.1.
Complete item 32, as appropriate. See DI 45010.045.
Complete item 39 as appropriate in accordance with POMS procedure. In addition, write “death” or “ceased,” then show the date of death or enter the appropriate of either the last day of the 36th month after the month of transplant or the last day of the 12 month after the month a course of dialysis ended.
NOTE: If equitable relief is involved, see DI 45010.045 C.
Complete items 37, 40, and 41.
Distribute copies of the SSA-892-U3 in the following manner: Prong file the original (folder) copy on the left side and release the DO and data copies without the folder.
NOTE: When the termination date is either impending or well in the future, prepare an SSA-1598 (per DI 45010.010) except in closed period or equitable relief cases, even if the termination date is to be changed from one established termination date for automatic and timely termination action. If no immediate termination action is required and the ESRD claimant is in DI/SSI disability status, forward the reporting event to a disability (CDR) examiner as soon as possible via Form SSA-567, as shown immediately below.
B. Possible CDR action
When the termination Medicare (ESRD) beneficiary is also in any DI or SSI disability (payment, suspense, or freeze) status, refer the case by Form SSA-567 to a disability (CDR) examiner after the terminating actions have been completed unless there is clear indication that CDR is in progress or was completed. Indicate on the SSA-567 “Possible medical improvement on related disability claim.”
C. Railroad involvement
When the terminating ESRD beneficiary is under the jurisdiction of RRB (MBR shows “P” option codes, prepare Form SSA-3103 as follows:
Enter the beneficiary's name and SSN in the appropriate blocks and the railroad claim number, if known.
In the “Remarks” section, enter “ESRD Medicare Termination—HI-SMI ends the last day of due to (transplant) (cessation of dialysis) which occurred in .”
Send to RRB at address below: