We must develop an application for ESRD Medicare (CMS-43) for all Disability (D-HI) beneficiaries. This is required because R-HI may continue after D-HI terminates. If retroactivity is involved, R-HI may even begin earlier.

Develop an application for ESRD Medicare from a beneficiary already entitled to Medicare based on age 65 only if:

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  The beneficiary is not currently enrolled in SMI;

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  The beneficiary is paying an increased premium due to late enrollment;

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  Entitlement to R-HI/R-SMI would be earlier than entitlement based on age 65; or

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  The beneficiary is entitled to premium-HI and/or SMI only.

If the beneficiary is age 65 or over and there is no advantage in filing for R-HI, destroy the CMS-2728, ESRD Medical Evidence Report Medicare Entitlement and/or Patient Registration.

We establish ESRD Medicare entitlement on the record on which the beneficiary is currently entitled, and deduct (SMI) premiums from the monthly benefit amount payable. Centers for Medicare & Medicaid Services (CMS) also bills for premiums under the same number when a person is not currently receiving a monthly payment because of Workers’ Compensation/Public Disability Benefit (WC/PDB) offset, or other nonpayment status. If the Railroad Retirement Board (RRB) has jurisdiction of monthly SSA benefits see, Processing End-Stage Renal Disease (ESRD) Medicare Claims with Railroad Retirement Board (RRB) Involvement DI 11052.010.

The following workflow is designed to get the ESRD claim on PC7's WMI list and to get DOWR credit for the field office.

1. 1. 

   When the claim is ready to clear, complete and transmit the DECI. Change the PC code if PC7 is not the PC shown. 

2. 2. 

   On the earnings comp request screen, say YES to adjudicate.

   • •

     If the DAPP screen comes up, answer NO to the Adjudication question.

   • •

     If you get a proc lim or exception, PF3 out.

3. 3. 

   Go to the interface (INTE) screen and overkey the BIC A to BIC T and Proc code "A".

4. 4. 

   This brings you to the M101 screen; PF3 to return to the INTE screen and overtype the Proc code to "N"  (if you get a red line remark “RECORD NIF on A101 CNTRL” you can ignore it).

5. 5. 

   Prepare form SSA-3601 for PC7 marked Initial Claim, Non-MCS, ESRD, Unprocessed. For required and conditional remarks see DI 11052.020F.

6. 6. 

   Fax the SSA 3601 into PC7 Paperless.

7. 7. 

   Route the claims material according to the instructions in DI 11052.035.

The Modernized Claims System/Earnings Computation (MCS/EC) processes an award or denial for a person filing for ESRD on his or her own record unless prior entitlement affects current insured status.

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  Run a pre-adjudicative EC in the MCS to review edits or alerts that may affect processing. In addition, query the Earnings Alert system (EARQ).

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  Input an allowance or a denial decision on the Decision Input (DECI) screen in MCS and establish any needed diaries.

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  Overkey the PC JURIS field to PC7 if necessary.

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  Document appropriate notices on NOT3 screen.

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  Process case through MCS/EC or A101 if adjudicative edit results from EC processing.

Establish an ESRD claim on the claimant’s own SSN in MCS.

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  On the ESRD screen in MCS, enter the SSN of the spouse or parent insured status is based upon.

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  For a spouse, also enter his or her SSN on the Number Holder Marriage (NMAR) screen. (EC determines insured status for the spouse or parent only when the SSN appears on the appropriate screens.)

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  Input an allowance or a denial decision on the DECI screen in MCS and establish any needed diaries.

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  Overkey the PC JURIS field to PC7 if necessary.

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  Document appropriate notices on NOT3 screen.

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  Prepare an A101 when an EC processing limitation results for these claims.

• •

  Prepare form SSA 3601 for PC7 marked Initial Claim, Non-MCS, ESRD, Unprocessed. For required and conditional remarks see DI 11052.020F.

EC does not have the capability to process concurrent claims at the same time. Use the following steps to process concurrent claims.

ESRD insured status requirements must be met.

1. a. 

   Obtain CMS-43 on the claimant’s own SSN.

2. b. 

   Complete Form SSA-892.

3. c. 

   Prepare an A101 on the claimant’s own SSN with a BIC of “T”.

   • •

     Enter the earlier of (1) the month of entitlement to ESRD Medicare or (2) the premium HI DOE as the HI entitlement date

   • •

     Enter the earlier of (1) the month of entitlement to SMI under the BIC “M” or (2) the ESRD Medicare as the SMI entitlement date

   • •

     Enter “See SSA-5002 in file for notice” in the remarks section. Determine appropriate notice

   • •

     If a beneficiary had premium HI, enter in remarks “Note to BTE: Beneficiary entitled to free HI effective _______. (MOE to R-HI).”

4. d. 

   Prepare a diary, if necessary.

   Prepare form SSA 3601 for PC7 marked Initial Claim, Non-MCS, ESRD, Unprocessed. For required and conditional remarks see DI 11052.020F.

NOTE: If we based insured status on Medicare Qualified Government Employment (MQGE) wages, use Beneficiary Identification Codes (BIC) TA on A101.

Reference:

HI 00801.440, Special Rules Applicable to MQGE Claims

EC triggers and releases the proper notice for the following disallowance codes. EC also triggers denial code 109 (other health insurance disallowance reason); however, you must include a paragraph explaining the reason for the disallowance on the Notice 3 (NOT3) screen in MCS. Refer to Notice 3 (NOT3) MSOM MCS 009.010.

ESRD related denial codes:

If the denial does not trigger through MCS, take the following actions:

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  Manually clear (MANCLR) the claim to your own FO code to lock the segment;

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  Input a denial via MACADE (show PC7 jurisdiction).