TN 31 (06-04)

HI 00801.235 Development of Claims

A. Policy

A complete claim consists of an application and evidence to show that the requirements in HI 00801.191 are met (or not met) and when R-HI entitlement begins based on dialysis, dialysis with self-care training, or a transplant.

B. Procedure — Taking the claim

1. Initial contact at FO

If a claimant for whom a CMS-2728-U3 has not been received visits an FO to file for R-HI, take the application (CMS-43 - Application for Health Insurance Benefits under Medicare for Individual with Chronic Renal Disease or MCS claim), as appropriate. Refer the individual to the ESRD facility for completion of the CMS-2728-U3.

NOTE: The FO is not responsible for completing any portion of the CMS-2728-U3. If a medical source contacts the FO to indicate that it does not have a stock of CMS-2728-U3 forms, mail a stock of forms to the source and advise the source to contact the ESRD Network for any assistance or instruction they require in completing the form.

2. CMS-43 received directly from ESRD facility

If the CMS-43 is received directly from the ESRD facility, begin development for non-medical factors of R-HI entitlement. Contact the ESRD facility for the required CMS-2728-U3 if it was not received with the application.

3. CMS-2728-U3 received from ESRD facility

When the form CMS-2728-U3 is received directly from an ESRD facility, contact the ESRD patient, or someone acting on his/her behalf, for completion of the application, CMS-43/MCS.

C. Procedure — Fully insured status

1. Definition

Consider the patient “fully insured” for ESRD purposes if he/she meets the requirements in HI 00801.191C.2. or HI 00801.261.

2. Request all earnings records

Unless the patient is a monthly beneficiary or obviously has the required QCs for fully or currently insured status on the SSN of a spouse or parent as appropriate, request a certified E/R on the patient's own SSN to ensure that all records are available immediately, if needed.

3. Other evidence

Obtain the same kind of evidence to establish relationship, child dependency, or insured status for ESRD cases as used in title II cases. See HI 00801.201C. for the policy on spouse or dependent child of insured person.

NOTE: Obtain evidence of whatever factor of entitlement is needed. For example, where a young person is insured, do not also develop relationship.

D. Procedure — SSN and BIC

Use the SSN and BIC as follows:

  • Where the R-HI claimant is entitled to monthly benefits, establish Medicare on the SSN and BIC under which he/she is receiving benefits.

    EXAMPLE: Ruby files for ESRD on her own SSN. However, since Ruby is entitled to monthly benefits as a ‘B' on her husband's SSN, Medicare based on ESRD is established on that record.

  • Where the R-HI claimant is not entitled to monthly benefits, establish Medicare on the claimant's own SSN with the BIC of T. If the claimant does not have an SSN, assign one.

    NOTE: This applies to those whose insured status is based on the earnings record of a spouse or parent, as well as to those insured based on their own earnings. If insured status is based on the earnings of a spouse or parent, the cross-reference SSN must be shown on the ESRD screen on MCS or the INS screen on MACADE.

  • Where concurrent claims (such as DWB and R-HI) have been filed and it is not clear at the time of the R-HI award whether monthly benefits have been awarded, use the claimant's own SSN and the BIC of T.

  • Where the R-HI claimant meets insured status based on his/her own MQGE earnings, establish Medicare on the claimant's SSN with the BIC of TA.

  • Where the R-HI claimant meets insured status based on a spouse or parent's MQGE earnings, establish Medicare on the NH SSN using the BIC of TB (spouse) or TC (child).

E. Procedure - Screening non-medical factors

If any non-medical factor of entitlement is not met:

  • Document the claim as to why the claimant is not eligible. Include a complete description of unsuccessful development efforts.

  • Follow the instructions in the MSOM for processing disallowances.

F. Procedure - Concurrent R-HI and DIB claims

If the claimant files concurrently for R-HI and for DIB:

  • Do not hold both claims until each is complete. Adjudicate (or forward) each claim separately as the particular development and adjudication is completed.

  • Associate photocopies of any evidence received with both claims, even if one claim has already been forwarded to ODO or, in the case of a DIB claim, to the State DDS.

  • Always forward ESRD claims to ODO (after DOFA procedures, if applicable) separately from the DIB claim.

  • Show “ESRD” on the face of the ESRD claims folder.

G. Procedure - RRB involvement

Develop and process all R-HI claims for persons whose insured status is based on RR service or entitlement to an RR annuity as if they were insured under title II.

Request confirmation of annuitant status or status of the spouse or parent (i.e., an RR microfiche or other acceptable record or statement) from the nearest RRB field office. The RRB web site www.rrb.gov has a zip code finder for all RRB offices.

Request the claimant's earnings record if he/she is not the annuitant or insured RR worker because the claimant's SSN is the one under which the R-HI claim is controlled and entitlement established.

Follow the instructions in DI 11052.010 or DI 45001.020 for processing RR cases.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600801235
HI 00801.235 - Development of Claims - 04/21/2015
Batch run: 04/21/2015
Rev:04/21/2015